Form Page

First Name*

Last Name*

Phone*

e.g. 555-555-5555

Email*

Did you wear the Yellow and Black ear plugs called Combat Arms CAEv2 Earplugs?*

Yes

Were you diagnosed with Hearing Loss or Tinnitus since returning home from a combat zone?*

Yes

Were you deployed between 2003 and 2015?*

Yes

Which ear(s) have a Tinnitus diagnosis? *

What percentage of hearing loss have you been diagnosed with?*

When would be a good time to call you?

Central Time