BTE CUSTOM EARMOLD - ReSound
2
L R L L L L L L L L L R R R R R R R R R SMALL LARGE L L L L L L L L R R R R R R R R GOVERNMENT SERVICES ORDER FORM BTE CUSTOM EARMOLD 1.800.392.9932 FAX 1.888.768.1867 LEFT 250 500 750 1k 1.5k 2k 3k 4k 6k 8k AC BC RIGHT 250 500 750 1k 1.5k 2k 3k 4k 6k 8k AC BC PATIENT INFORMATION LAST NAME FIRST NAME LAST 4 DIGITS OF SSN: IMPRESSION (check): OPEN JAW CLOSED JAW SPECIAL INSTRUCTIONS TRUFIT™ IMPRESSION—THE 16/4 RULE Take an OPEN JAW impression when: • Ear geometry lacks retention • Patient has severe TMJ movement • Instrument migrates out of ear • Instrument is loose or has feedback Full helix 4mm 16mm ACCOUNT INFORMATION ACCOUNT # ACCOUNT NAME ADDRESS CITY STATE ZIP PO # CONTACT NAME PHONE NUMBER RACHAP ACTIVE DUTY INDIAN HEALTH TRICARE CHOICE MATERIAL Hard (acrylic) Soft (silicone) L L L L L L L L R R R R R R R R INSTRUMENT INFORMATION MODEL COLOR Clear ...................................... Light ...................................... Medium ................................... Dark ...................................... Rose (hard only) ............................. EarLusion Light ............................ Espresso (hard only) ......................... Red/Blue .................................. CANAL LENGTH Factory select ................................. As marked ..................................... VENTING Factory select ................................. MOV (Semi-IROS vent modification recommended) .... SAV (standard for Flex Vent) ....................... Pressure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None (standard for Open Skeleton) ................. VENT MODIFICATION Semi-IROS .................................... IROS .......................................... COUPLING Thin Tube (default for Flex Vent) ................... Size 13 Standard ................................... 13 Standard—dry .............................. 13 Heavy wall. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . TUBE RETENTION Glue .......................................... Through (no glue) ............................... Elbow ......................................... Tube lock—metal (soft only) ..................... Tube lock—plastic (soft only)..................... CFA adapter (soft only) .......................... OTHER OPTIONS Removal cord .................................. Blue/Red dots .................. Size (check one): Patient initials .................... PLEASE SEND Air bills Impression mailers AVAILABLE DEFAULT CANAL CANAL LOCK SEMI-SKELETON FLEX VENT HALF SHELL SKELETON OPEN SKELETON FULL SHELL L L R R L L L L L L L L R R R R R R R R
Transcript of BTE CUSTOM EARMOLD - ReSound
L R
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L
LLL
LLL
RR
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SMALL LARGE
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GOVERNMENT SERVICES ORDER FORM
BTE CUSTOM EARMOLD1.800.392.9932 FAX 1.888.768.1867
LEFT 250 500 750 1k 1.5k 2k 3k 4k 6k 8k
AC
BC
RIGHT 250 500 750 1k 1.5k 2k 3k 4k 6k 8k
AC
BC
PATIENT INFORMATION
LAST NAME
FIRST NAME
LAST 4 DIGITS OF SSN:
IMPRESSION (check): OPEN JAW CLOSED JAW
SPECIAL INSTRUCTIONS
TRUFIT™ IMPRESSION—THE 16/4 RULE
Take an OPEN JAW impression when:• Ear geometry lacks retention• Patient has severe TMJ movement• Instrument migrates out of ear• Instrument is loose or has feedback
Full helix4mm
16mm
ACCOUNT INFORMATION
ACCOUNT #
ACCOUNT NAME
ADDRESS
CITY STATE ZIP
PO #
CONTACTNAME PHONE NUMBER
RACHAP
ACTIVE DUTY
INDIAN HEALTH
TRICARE
CHOICE
MATERIAL
Hard (acrylic) Soft (silicone)
L
L
L
L
L
L
L
L
R
R
R
R
R
R
R
R
INSTRUMENT INFORMATION MODEL
COLORClear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Light . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Medium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Dark . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Rose (hard only) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .EarLusion Light . . . . . . . . . . . . . . . . . . . . . . . . . . . . Espresso (hard only) . . . . . . . . . . . . . . . . . . . . . . . . .
Red/Blue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CANAL LENGTHFactory select . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .As marked . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
VENTINGFactory select . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .MOV (Semi-IROS vent modification recommended) . . . .SAV (standard for Flex Vent) . . . . . . . . . . . . . . . . . . . . . . .Pressure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None (standard for Open Skeleton) . . . . . . . . . . . . . . . . .
VENT MODIFICATIONSemi-IROS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .IROS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
COUPLING Thin Tube (default for Flex Vent) . . . . . . . . . . . . . . . . . . .
Size 13 Standard . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Standard—dry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Heavy wall. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
TUBE RETENTIONGlue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Through (no glue) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Tube lock—metal (soft only) . . . . . . . . . . . . . . . . . . . . .Tube lock —plastic (soft only) . . . . . . . . . . . . . . . . . . . . .CFA adapter (soft only) . . . . . . . . . . . . . . . . . . . . . . . . . .
OTHER OPTIONSRemoval cord . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Blue/Red dots . . . . . . . . . . . . . . . . . . Size (check one):
Patient initials . . . . . . . . . . . . . . . . . . . .
PLEASE SEND Air bills Impression mailers
AVA
ILA
BLE
D
EFA
ULT
CANAL
CANAL LOCK
SEMI-SKELETON
FLEX VENT
HALF SHELL
SKELETON
OPEN SKELETON
FULL SHELL
LL
RR
L
L
L
LLLLL
R
R
R
RRRRR
LLLL
RRRR
LLL
RRR
LLLLL
RRRRR
LLLLLLL
RRRRRRR
LLLL
RRRR
RECEIVER Include (circle): Size: Low power (LP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Medium power (MP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .High power (HP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Ultra power (UP) (Encased) . . . . . . . . . . . . . . . . . . . . . . . . . . .
SHELL COLORClear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Light . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Medium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Dark . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Rose (n/a for Encased nor Hollow Cavity) . . . . . . . . . . . . . .EarLusion Light (n/a for Encased nor Hollow Cavity) . . . Espresso (hard only) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Red/Blue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
FACEPLATE COLOR (Encased only)Light . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Beige . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Medium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Dark . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Espresso . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Anthracite . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Clear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CANAL LENGTHFactory select . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .As marked . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
VENTINGFactory select . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .MOV (Semi-IROS vent modification recommended) . . . . . . . . .SAV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Pressure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .None . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
VENT MODIFICATION (n/a for Hollow Cavity)Semi-IROS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .IROS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
WAX PROTECTION (Encased and hard only, n/a for Hollow Cavity)HF3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CeruSTOP (default for Encased) . . . . . . . . . . . . . . . . . . . . . . . .None (default for hard, STD for Hollow Cavity) . . . . . . . . . . . . .
OTHER OPTIONSRemoval cord . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Blue/Red dots . . . . . . . . . . . . . . . . . . . Size (check one):
Patient initials. . . . . . . . . . . . . . . . . . . . . . . . RETENTION
Canal Lock (n/a for Skeleton) . . . . . . . . . . . . . . . . . . . . . . . . .Helix Lock (n/a for Hollow Cavity and Skeleton) . . . . . . . . .Skeleton Lock (n/a for Skeleton) . . . . . . . . . . . . . . . . . . . . . .Semi-Skeleton Lock (n/a on Hollow Cavity and Skeleton)
ENCASED
MICROMOLD
HOLLOW CAVITY
SKELETON
GOVERNMENT SERVICES ORDER FORM
SUREFIT RIC CUSTOM EARMOLD1.800.392.9932 FAX 1.888.768.1867
MK604954 Rev C 2019.04
RACHAP
ACTIVE DUTY
INDIAN HEALTH
TRICARE
CHOICEPATIENT INFORMATION
LAST NAME
FIRST NAME
LAST 4 DIGITS OF SSN:
IMPRESSION (check): OPEN JAW CLOSED JAW
SPECIAL INSTRUCTIONS
ACCOUNT INFORMATION
ACCOUNT #
ACCOUNT NAME
ADDRESS
CITY STATE ZIP
PO #
CONTACTNAME PHONE NUMBER
LEFT 250 500 750 1k 1.5k 2k 3k 4k 6k 8k
AC
BC
RIGHT 250 500 750 1k 1.5k 2k 3k 4k 6k 8k
AC
BC
INSTRUMENT INFORMATION MODEL
MATERIAL
Hard (acrylic) Soft (silicone)
(n/a for Encased and Hollow Cavity)
L
L
L
L
R
R
R
R
YES NO
L
L
L
L
LL
LLLLLLL
R
R
R
R
RR
RRRRRRR
AVA
ILA
BLE
D
EFA
ULT
SMALL LARGE
TRUFIT™ IMPRESSION—THE 16/4 RULE
Take an OPEN JAW impression when:• Ear geometry lacks retention• Patient has severe TMJ movement• Instrument migrates out of ear• Instrument is loose or has feedback
Full helix
16mm
4mm
MK604954
