Earmold Order Form - PhonakPro · Earmold Order Form. Step 1: Order BTE Product. Other: Patient...
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Earmold Order Form Step 1: Order BTE Product Other: Patient Information L R 90 70 50 30 Instrument ¨ ¨ ¨ ¨ ¨ ¨ Phonak Bolero B-M ¨ ¨ ¨ ¨ ¨ ¨ Phonak Bolero B-P ¨ ¨ ¨ ¨ ¨ Phonak Bolero B-PR ¨ ¨ ¨ ¨ ¨ ¨ Phonak Bolero B-SP ¨ ¨ ¨ ¨ ¨ ¨ Phonak Naída B-SP ¨ ¨ ¨ ¨ ¨ ¨ Phonak Naída B-UP ¨ ¨ Phonak CROS B-312 1,2 ¨ ¨ Phonak CROS B-13 1,2 ¨ ¨ Phonak CROS B-R 1,3 L R 90 70 50 30 Instrument ¨ ¨ ¨ ¨ ¨ ¨ Phonak Bolero ™ M-M ¨ ¨ ¨ ¨ ¨ ¨ Phonak Bolero M-PR ¨ ¨ ¨ ¨ ¨ ¨ Phonak Naída ™ M-SP ¨ ¨ ¨ ¨ ¨ Phonak Sky ™ M-M ¨ ¨ ¨ ¨ ¨ Phonak Sky M-PR ¨ ¨ ¨ ¨ ¨ Phonak Sky M-SP 1 Only compatible with Belong products 2 Not compatible with Rechargeable models 3 Only compatible with Audéo B-R 4 Not available on Sky M/B Step 2: Color Color: H0/01 Beige Q2 Electric Green Q3 Caribbean Pirate T3 Precious Pink M6 Lava Red M7 Blue Ocean M8 Majesty Purple P6 Silver Gray P8 Velvet Black P5 Champagne P7 Graphite Gray 4 T7 Alpine White P1 Sand Beige P3 Sandalwood P4 Chestnut Exclusive to Sky M/B and CROS B-13: Marvel Belong Customer Information Date: Ship To Account Number: Address: City: State: Zip: Bill To Account Number: Third Party Patient Number: Purchase Order Number: Contact Name: Phone: Email: Last Name: First Name: Age: Gender: Hz 250 500 1K 2K 3K 4K Left: AC Right: AC Audiogram (Required for AOV): HI Warranty n 2 nd year n 3 rd year n 4 th year
Transcript of Earmold Order Form - PhonakPro · Earmold Order Form. Step 1: Order BTE Product. Other: Patient...
Earmold Order Form
Step 1: Order BTE Product
Other:
Patient Information
L R 90 70 50 30 Instrument
¨ ¨ ¨ ¨ ¨ ¨ Phonak Bolero B-M
¨ ¨ ¨ ¨ ¨ ¨ Phonak Bolero B-P
¨ ¨ ¨ ¨ ¨ Phonak Bolero B-PR
¨ ¨ ¨ ¨ ¨ ¨ Phonak Bolero B-SP
¨ ¨ ¨ ¨ ¨ ¨ Phonak Naída B-SP
¨ ¨ ¨ ¨ ¨ ¨ Phonak Naída B-UP
¨ ¨ Phonak CROS B-312 1,2
¨ ¨ Phonak CROS B-13 1,2
¨ ¨ Phonak CROS B-R1,3
L R 90 70 50 30 Instrument
¨ ¨ ¨ ¨ ¨ ¨ Phonak Bolero™ M-M
¨ ¨ ¨ ¨ ¨ ¨ Phonak Bolero M-PR
¨ ¨ ¨ ¨ ¨ ¨ Phonak Naída™ M-SP
¨ ¨ ¨ ¨ ¨ Phonak Sky™ M-M
¨ ¨ ¨ ¨ ¨ Phonak Sky M-PR
¨ ¨ ¨ ¨ ¨ Phonak Sky M-SP
1 Only compatible with Belong products2 Not compatible with Rechargeable models3 Only compatible with Audéo B-R4 Not available on Sky M/B
Step 2: Color
Color:
H0/01Beige
Q2Electric Green
Q3Caribbean Pirate
T3Precious Pink
M6Lava Red
M7Blue Ocean
M8Majesty Purple
P6Silver Gray
P8Velvet Black
P5Champagne
P7Graphite Gray 4
T7Alpine White
P1Sand Beige
P3Sandalwood
P4Chestnut
Exclusive to Sky M/B and CROS B-13:
Marvel Belong
Customer Information
Date:
Ship To Account Number:
Address:
City: State: Zip:
Bill To Account Number:
Third Party Patient Number:
Purchase Order Number:
Contact Name:
Phone:
Email:
Last Name:
First Name:
Age: Gender:
Hz 250 500 1K 2K 3K 4K
Left: AC
Right: AC
Audiogram (Required for AOV):
HI Warranty
n 2nd year n 3rd year n 4th year
2020
-04/
© S
onov
a U
SA In
c. A
ll rig
hts
rese
rved
.
Step 3: Select Coupling (defaults in bold) Earmolds StyleL R Phonak CROS [CB]L R Phonak Canal Lock [CL]L R Phonak Canal [CU]L R Phonak Semi-Skeleton [SS]L R Phonak Skeleton [SK]L R Phonak Half-Shell [HC]L R Phonak Carved Full Shell [SC]L R Phonak Standard Full Shell [SU]L R Phonak Helix Lock [HL]
Canal LengthL R Short [CS]L R Medium [CM]L R Long [CL] L R Cut as marked [R.]
OptionsL R Helix LockL R Removal Line [RF]L R Bell Bore [A2]L R Color Dot [CD]L R No Glue [NG] (Tubing)
ColorL R Clear [CL] L R BrownL R Tinted Pink
MaterialL R Acrylic [AC]L R Silicone [S70]
VentingL R AOV [AO]L R Large SAV [S30]L R IROS A [IA30]L R Large Vent [P30]L R Medium [P25]L R Small [P20]L R Pressure [P12]L R No Vent [X]
Vents are drilled parallel as a default. If the physical size of the earmold or acoustic requirements prevent us from using a parallel vent, we will install a merged vent.
TubingL R 13 Standard Clear [13M]L R 13 Thick Clear [13T]L R Dry Tubing [13D]L R Quick Snap TLG tubing
(Acrylic only)L R Tube Lock [TRS] (Silicone only)
Sky B Power Slim Tube IIL R 00L R 0 L R 1L R 2 L R 3
Available with Sky B-SP and Sky B-UP only
Step 5: Notes and Special Instructions
n Call if changes are required
n No phone call required to make changes
Step 4: Remotes and Wireless Accessories
Marvel
n Phonak PilotOne II n TVLink II
n Phonak ComPilot Air II n Phonak RemoteMic
n Phonak ComPilot II
Belong
n TV Connector n Roger Select™ iN
n Phonak Remote Control n Roger Pen™ iN
n Phonak PartnerMic™ n Roger Table Mic II iN
Phonak CROS
Phonak Skeleton
Phonak Semi-Skeleton
Phonak Canal
Phonak Canal Lock
Phonak Helix Lock
Phonak Half Shell
Phonak Full Shell Carved
Phonak Standard Full Shell
