Please Note: The Custom Protect Ear “Re-order Form” is only for customers that have current (within the last 5 years) ear mold-impressions on file with Custom Protect Ear.

    Serial Number:
    This is the best way of tracking your DB Blocker. Serial Numbers can be found on cards or tags

    To ensure your order is processed in a timely fashion, please enter as much information as you can.

    Note: All Fields with a * are mandatory.

    Personal Information

    Shipping Address
    (If different from personal information)

    Please enter your employer information if applicable:

    What method of payment will you provide:

    What colour would you like?

    Is this the same as you have ordered before?

    Please enter the best contact information we can reach you to obtain credit card information: