CUSTOMER INFORMATION

SELECT SERVICE (Must complete)

PATIENT INFORMATION

CAMISHA CUSTOM SHELL ORDER FORM

Bill-to Account Number: _______________________________________________

Ship-to Account Number: ______________________________________________

Address: ___________________________________________________________

__________________________________________________________________

City: _____________________________________State:_____ Zip: ___________

Contact Name: ______________________________________________________

Phone: ______________________________ Email: ________________________

If no service selected, Widex will only process the custom shell order. No receiver will be sent.

Custom shell only. Proceed to Steps 1 and 2. Custom shell pre-assembled to wired receiver. Proceed to Steps 1 and 2. Custom shell pre-assembled with hearing aid or CROS. Proceed to Steps 1, 2, 4 thru 7. Instant ear-tip with hearing aid or CROS. Proceed to Steps 3 thru 7.

Use previous CAMISHA scan(s) to manufacture this order.

Right Serial #: ____________________ Left Serial #: ____________________

NOTE: See Widex Price & Policy Guide for price information.

Standard Canal Lock Extended

Canal Lock Concha Lock Half

Skeleton LockSkeleton

Lock Helix Lock Full Shell

LockLock If yes, indicate lock type:

_____ _____

Lock If yes, indicate lock type:

_____ _____

STEP 1: SELECT CUSTOM SHELL TYPE (Proceed to Step 3 if instant ear-tip is desired.)

EMBE

DD

ED R

IC

A. B. C. D. E. F. G. H.

Date:______________________________________________________________

First Name: _________________________________________________________

Last Name: _________________________________________________________

Pediatric Order: Age: ________________________________________

If no vent option is selected on this order form, Widex will select the appropriate vent based on the Audiometric Data provided.

Audiometric Information Widex may change from hard to soft material to accommodate your order request. Would you like to be consulted before this change is made? Widex may decrease the vent size to accommodate your order request. Would you like to be consulted before this change is made?

Fitting Date: ________________________________________________________

RITE custom shell orders only: If this order is within 90 days of the BTE invoice/patient fi t date, provide the BTE serial numbers.

Right Serial #: _______________________ Left Serial #: _____________________

250Hz 500Hz(Required) 1kHz 2kHz 3kHz 4kHz

Right

Left

RIC/

THIN

TU

BE

MO

DU

LAR

RIC

RITE

Design Receiver/Thin Tube Size Material/Color VentingMay vary due to ear canal size

Additonal Options Wire/Thin Tube Length

Hard Hollow

Hard Solid (extended ear-tip)

Open Hard (For S&M receivers only)

Soft

S M P

Hard Clear (Flex Hard Solid Shell onlyavailable in Hard Clear)

Hard Beige Hard Medium Brown Soft Clear

Straight: Trench (For Soft Shell Only):No Vent XS S M L XL XXL Max Vent Open (No venting needed)

Soft HypoallergenicCoat (Hard only) Hard HypoallergenicCoat (Hard only) Nano HypoallergenicCoat (Soft only) Retention Ring Thick Removal Line

R 01234

L 01234

Thin Tube:

0.9mm 1.4mm élan Tube (DREAM9 BTE only; notavailable for Hard Solid)

Design Receiver Material/Color Venting Additional Options Wire/ Length

Hard 1/2*

Hard 3/4*

Hard Full*

*With Straight Bore - Standard

HP SP

Beige Medium Brown Clear

Straight:No Vent XS S M L XL Max Vent

Output Extender (Hard Shell only)

Soft HypoallergenicCoat Hard HypoallergenicCoat Removal Notch Removal Line Retention Ring

R -2-1012345

L -2-1012345

Soft Full Wired HP (For FUSION only)

Wired SP (For SUPER only)

BABY440 (For BABY440 only)

Clear Trench:No Vent XS S M L XL Max Vent

Hypoallergenic Coat No Helix Retention Ring

(Sizes -1 and -2 only available for BABY440)

Design Receiver Material/Color Venting Additional Options Wire/ Length

Embedded Hard

Modular Hard

S M P HP SP (For HP/SP, impression length must include 2nd bend)

Hard Clear (Standard)

Straight:No Vent XS S M L XL XXL Max Vent

Soft HypoallergenicCoat Hard HypoallergenicCoat Retention Ring Removal Line Thick Removal Line Canal Lock

R -1012345

L -1012345

(-1 and 5 not available for embedded)

MO

DU

LAR/

EMBE

DD

EDRE

CEIV

ER-I

N-T

HE-

EAR

(RIT

E) E

ARM

OLD

RIC/

THIN

TU

BE

STEP 2: SELECT A CUSTOM SHELL OPTION

(Removal string added as standard)

(Removal string added as standard)

DF

M58

_0218

Order online at www.widexpro.com

ProductsWarm Beige

Summer Gold

Copper Brown

Cappuccino Brown Tan Silk

Winter Silver

Titan Grey

Midnight Black

Silver White

Pearl White

Metallic Blue

Shocking Pink

Lime Green

Sporty Red

Med Turquoise

BEYOND Z FUSION2 * * * * * * * * * * * * *

BEYOND FUSION2

UNIQUE FASHION MINI

UNIQUE FUSION DREAM FUSION UNIQUE PASSION DREAM PASSION UNIQUE FASHION DREAM FASHION CROS FUSION CROS FASHION

DREAM m-SERIES DREAM 9 BTE

Select Product Select Level Select Model

BEYOND Z 440 330 220

FUSION2 Z (ZEN Standard)

BEYOND 440 330 220

FUSION2 (ZEN Standard)

UNIQUE 440 330 220 110

FUSION FASHION PASSION FASHION MINI (ZEN Standard in all models)

DREAM 440 330 220 110

FUSION FASHION PASSION m-Micro

9 BTE(DREAM9 BTE only)

(ZEN Standard in all models)

CROS N/A FUSION FASHION

BABY440 N/A BABY440

SUPER 440 220 SUPER440 VS SUPER220 VS (ZEN: ) SUPER440 VSD SUPER220 VSD (ZEN: )(ZEN Standard in 440 only)

Platinum (Standard) Gold Transparent

RC2-DEX: Silver _______

Black _______

COM-DEX: White _______

Grey ________

Green _______

COM-DEXRemote Mic: Grey ________

UNI-DEX: Black _______

FM+DEX: Silver _______

ADD’L TV-DEX BASE: Silver _______

TV-DEX: Silver _______

PHONE-DEX: Silver _______

CALL-DEX: Black _______

STEP 6: SELECT ACCESSORIES (Indicate quantity)

021 069 070 081 072 073 074 112 090 077 075 076 078068071

BABY440

Pearl White

Pearl Pink

Pearl Blue

SUPER

Black Brown Charcoal Grey

NOTE: See Widex Price & Policy Guide for price information.

068 084 085

NOTES: ____________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________

STEP 5: SELECT MIC GRID (For BEYOND, FUSION and PASSION only)

STEP 4: SELECT HEARING INSTRUMENT

STEP 7: SELECT HEARING AID COLOR

*Color available Q1, 2018

STEP 3: SELECT INSTANT EAR-TIP (Please complete ONLY if no custom shell has been selected.)

Receiver/Thin Tube Size Instant Ear-Tip RIC and Thin Tubes Wire/Thin Tube Length

S M P

Open

XS S L(Open ear-tip not available for P receiver)

Double

XS S M L

Tulip

M L

R 01234

L 01234

Thin Tube:

0.9mm 1.4mm élan Tube (DREAM9 BTE only)

INST

AN

T