Phonak Custom Earmold Order FormAdditional Information

Please fill in client/order detailsEnter delivery date

Audiogram Required for AOV

Order Details

Select Earmold Style and Options

Select earmold style by ticking (L)left (R)right or (LR) for bothSelect earmold canal lengthSelect earmold material, color and lacquer optionsSelect tube type and color/ select connector typeFor Naida S Power SlimTube indicate tube size for left and right (see „Measure tube length“ below)

Enter patient audiogram for Acoustically Optimized VentingAOV Acoustically Optimized Vent is available for Spice Hearing Instruments Only.

Specify BTE Hearing Instrument Type

Special Instructions, needs, wishes

Indicate the instrument to be fitted with the ordered earmoldIndicate whether you wish the BTE(s) to be delivered with the earmold(s)

Enter special wishes as neededSelect Rush Order option if required

Helix/Cymba

First Bend

Intertragal Notch

Ventilation boreAOV Acoustically Optimized Venting

Sound bore

Tragus

Crus

Concha rim

Anti-Tragus

6

5

4321

7

Please Note a $45 charge will apply to all earmolds

The QuickSnap system is an easy exchangeable earmold tube with connector. Tube exchange was never so easy. No more drilling and glueing just exchange the tube by a click!See the order pages for the tube type and color options.

Connector QuickSnap (TLG)

Earmold areas Step by Step Order entry

Measure tube length (Power SlimTube)

Use Phonaks’ measurement tool to identify the corresponding tube length (00/0/1/2/3).The picture below shows the required tube length. For this ear size „1"would need to be ordered

Naming of ear areas 0

Custom Earmold with AOV Order FormAdditional Information

Please fill in client/order detailsEnter delivery date

Audiogram Required for AOV

Order Details

Select Earmold Style and Options

Select earmold style by ticking (L)left (R)right or (LR) for bothSelect earmold canal lengthSelect earmold material, color and lacquer optionsSelect tube type and color/ select connector typeFor Naida S Power SlimTube indicate tube size for left and right (see „Measure tube length“ below)

Enter patient audiogram for Acoustically Optimized Venting

Specify BTE Hearing Instrument Type

Special Instructions, needs, wishes

Indicate the instrument to be fitted with the ordered earmoldIndicate whether you wish the BTE(s) to be delivered with the earmold(s)

Enter special wishes as neededSelect Rush Order option if required

Helix/Cymba

First Bend

Intertragal Notch

Ventilation boreAOV Acoustically Optimized Venting

Sound bore

Tragus

Crus

Concha rim

Anti-Tragus

Phonak CPS - Generic Custom Orderform March 2011

6

5

4321

7

The QuickSnap system is an easy exchangeable earmold tube with connector, for use with thick wall tubing only. Tube exchange was never so easy. No more drilling and glueing just exchange the tube by a click! See the order pages for the tube type and color options

Connector QuickSnap

Earmold areas Step by Step Order entry

Measure tube length (Power SlimTube) Naida S only

Use Phonak’s measurement tool to identify the corresponding tube length (00/0/1/2/3).The picture below shows the required tube length. For this ear size “1” would need to be ordered.

Naming of ear areas 0

Earmold Pricing (Private Pay)Earmold ordered with Phonak BTE Hearing Instrument: $50Earmold only: $50

Earmold Warranty:Phonak earmolds are guaranteed against defects in material or workmanship for one year. Remakes are free within 90 days of purchase. Earmolds cannot be returned for credit. There is no loss and damage warranty on earmolds.

Connector QuickSnap (TLG) The QuickSnap system is an easy exchangeable earmold tube with connector. Tube exchange was never so easy. No more drilling and glueing just exchange the tube by a click! See the order pages for the tube type and color options.

Earmold areasNaming of ear areas

Measure tube length (Power SlimTube) Use Phonaks’ measurement tool to identify the correspond-ing tube length (00/0/1/2/3). The picture to the right shows the required tube length. For this ear size “1” would need to be ordered

Custom Earmold with AOV Order FormAdditional Information

Please fill in client/order detailsEnter delivery date

Audiogram Required for AOV

Order Details

Select Earmold Style and Options

Select earmold style by ticking (L)left (R)right or (LR) for bothSelect earmold canal lengthSelect earmold material, color and lacquer optionsSelect tube type and color/ select connector typeFor Naida S Power SlimTube indicate tube size for left and right (see „Measure tube length“ below)

Enter patient audiogram for Acoustically Optimized Venting

Specify BTE Hearing Instrument Type

Special Instructions, needs, wishes

Indicate the instrument to be fitted with the ordered earmoldIndicate whether you wish the BTE(s) to be delivered with the earmold(s)

Enter special wishes as neededSelect Rush Order option if required

Helix/Cymba

First Bend

Intertragal Notch

Ventilation boreAOV Acoustically Optimized Venting

Sound bore

Tragus

Crus

Concha rim

Anti-Tragus

Phonak CPS - Generic Custom Orderform March 2011

6

5

4321

7

The QuickSnap system is an easy exchangeable earmold tube with connector, for use with thick wall tubing only. Tube exchange was never so easy. No more drilling and glueing just exchange the tube by a click! See the order pages for the tube type and color options

Connector QuickSnap

Earmold areas Step by Step Order entry

Measure tube length (Power SlimTube) Naida S only

Use Phonak’s measurement tool to identify the corresponding tube length (00/0/1/2/3).The picture below shows the required tube length. For this ear size “1” would need to be ordered.

Naming of ear areas 0

www.phonakpro.ca

Prelocked Tubing (TRS) For all soft earmolds

Step 1 Order Details Step 2 Select Earmold Style Step 3 Select Canal Length

Select whether you wish the BTE(s) to be delivered with the earmold(s) or send earmold(s) only. c Earmold (Private Pay $50 each) sent with

BTE Hearing Instrument c L Model: _____________________ L Colour Code: ___________(eg. F5)

c R Model: _____________________ R Colour Code: ___________(eg. F5)

OR c Earmold only (Private Pay $50 each) Please also send me the following accessories:

__________________________________

__________________________________

__________________________________

Our default configurations§ Acrylic hard transparent§ 13 Medium Tube§ Medium Canal Length

Step 4 Earmold Materials Step 5 Tube/Connector Details

Step 6 Venting Step 7 Special Instructions

Audiogram (Required for AOV) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Phonak Custom Earmold Order Form Phone: 905-677-1167 or 1-800-876-1167 Fax: 905-677-7536 or 1-800-814-5799

Ship to Account Number:

Bill to Account Number: Phone#:

Company Name:Address:Contact Name (Audiologist/Dispenser):Claim Type: mVAC/NIHB/RCMP mWCB-AB mWS-BC mWCB-MB mWSIB

mCSST mREGIE mOther: ____________________________

Client Information M c F c

User Name: Last ccccccccccc

First cccccccccccmPaediatric Date of Birth:______ / _______ / _______ DD MM Year

Claim # (Required): ccccccccccc

Changes may be made without calling

Right Left Binaural

SRT

MCL

UCL 250 500 1K 2K 3K 4K

Speech Scores

p dB HL p dB SPLL

R

(Please print)

025-

0574

Pho

nak

Cust

om E

arm

old

Ord

er F

orm

Nov

embe

r 20

12 F

orm

27

S: Standard configuration

Colour Lacquer Finish

Earmold materials Clea

r/Tr

ansp

aren

t (2

1)

Rose

Tin

t (T

)

Tran

spar

ent

Brow

n (N

)

Lacq

uer

Acry

lic h

ard/

soft

- G

loss

y fin

ish

Lacq

uer

Acry

lic h

ard

- M

att

finis

h

Acrylic hard (lucite) c L c R S S

Silicone soft 70* c L c R S NA NA S NA

Silicone very soft 40* c L c R S NA NA S NA

Canal Moldc L c R

Canal Lockc L c R

Helix Lockc L c R

Semi Skeletonc L c R

Skeletonc L c R

Carved Half Shellc L c R

Carved Full Shellc L c R

Full Shellc L c R

ID: Inner Diameter OD: Outer Diameter * Transparent tube only

Colour Con.

Tube/Connector details

Air

tube

leng

th

Clea

r/Tr

ansp

aren

t (2

1)

Rose

Tin

t (M

4)

Tran

spar

ent

Brow

n (L

7)

Conn

ecto

r Q

uick

Snap

(TLG

)

00/0/1/2/3

13 Medium Tube (ID 1.9, OD 3.2) 13M c L c R NA S

13 Thick Wall Tube (ID 1.9, OD 3.3) 13T c L c R NA

13 Dry Wall Tube (ID 1.9, OD 3.2) 13D c L c R NA *13 Dry Thick Wall Tube (ID 1.9, OD 3.3) 13W c L c R NA *Power SlimTube Naida S only (ID 1.4, OD 2.0) PST NA NA NAL R

Date : ______ / _______ / _______ DD MM Year

c Rush order in 48h ($39.00 charge)

PO#: _______________________

Attention to (at Phonak): ________________________________

c AOV Acoustically Optimized Vent (Quest & Spice+ Hearing Instruments Only)

OR

c Vent Size: Customer Specified: c L ______ c R ______

SS

Canal LengthLeft c Short c Med. c LongRight c Short c Med. c Long

Ear Texturec Soft c Avg. c Firm

*Soft earmolds come standard with prelocked tubing (TRS)