Any person who engages in fitting and dispensing of hearing instruments shall provide to each person who enters into an agreement to purchase a hearing instrument a receipt at the time of the agreement containing the following information:
(1) The seller's name, signature, license, or permit number, address, and phone number of his or her regular place of business;
(2) A description of the instrument furnished, including make, model, circuit options, and the term "used" or "reconditioned" if applicable;
(3) A disclosure of the cost of all services including but not limited to the cost of testing and fitting, the actual cost of the hearing instrument furnished, the cost of ear molds if any, and the terms of the sale. These costs, including the cost of ear molds, shall be known as the total purchase price. The receipt shall also contain a statement of the purchaser's recision rights under this chapter and an acknowledgment that the purchaser has read and understands these rights. Upon request, the purchaser shall also be supplied with a signed and dated copy of any hearing evaluation performed by the seller.
(4) At the time of delivery of the hearing instrument, the purchaser shall also be furnished with the serial number of the hearing instrument supplied.