Any person who practices the fitting or dispensing of hearing aids shall provide to each purchaser of a hearing instrument, a purchase agreement which shall contain the licensee’s printed name, signature, address of regular place of practice and licensee number. The purchase agreement shall include the brand, model, style, type of technology, warranty and the amount charged for the hearing instrument furnished to the consumer. The purchase agreement shall also include the condition of the hearing instrument and whether it is assembled, new, used or rebuilt.