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Home > Otology Products > EarPopper

EarPopper® Ear Relief Order Form

In the US, you must first obtain a prescription from a health care provider before you are able to order an EarPopper.
If your provider is not familiar with the EarPopper you can print out our brochure and bring it with you during your appointment.

If you would like a referral for a physician in your area that is familiar with the EarPopper, contact us at 1-888-229-2875.

Purchasing the EarPopper online with us is fast and easy. The cost is $169.99. Please complete all information on the order form below and once we verify your prescription, the EarPopper will be shipped (ground) to you for free in the continental U.S*.
*Offer valid on orders placed direct through Summit Medical only.

NOTE : Patient will be responsible for contacting their insurance provider with reimbursement inquiries.

Please fill out the order form below. Fields marked with an asterisk (*) are required.


Who is this EarPopper for?

Patient Information

Patient Name:*
Date of Birth*: (required for prescription verification)
Date of Prescription*:


Who prescribed the EarPopper?

Provider Information

Prescribing Health Care Provider’s Name:*
Clinic or
Business Name:*
Address:*
City:*
State:*
Zip:*
Phone Number:*


Billing Information:

Date:
Name:*
Address:*
Address:
City:*
State:* 
Zip:* 
Phone Number:*
E-mail:*


Shipping Information:
Use Billing Address

Name:*
Address:*
Address:
City:*
State:* 
Zip:* 


Order

Product # Qty* Description Price Total
EP-2100 EarPopper $169.99 $


UPS Ground shipping included within the 48 contiguous states. Residents of Alaska and Hawaii should contact us for rate information. Please also contact us for expedited shipping rates.

NOTE: Orders received after 2:00 PM CST will be shipped the next business day.


Payment Method

Credit Card:
3 Digit Code Shown on Back of Card
Card Number:
3 Digit Code on Back of Card:*
Expiration Date:


How did you hear about EarPopper?*

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Comments/Questions:

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