HearUSAVelox Custom Order Form

(All fields required)

Ship to Account:

Account Name:

Address:

City: State: Zip:

Phone #:

Bill to Account:

Date: Fitting Date:

Purchase Order #:

First Name:

Last Name:

Medicaid #:

Fitter’s Name: Order Place Name:

Fitter’s Email (required): Order Placer Email (required):

Select Model: Opn 1 Opn 2 Opn 3 Siya 1 Siya 2

1 Year Repair

1 Year Extended

1 Year Replacement(excludes Opn 3 & Siya)

Audiometric Information (required)

Step 3: Warranty - Additional

Step 4: Contact Information

Step 2: Patient InformationStep1: Ship To Information

Invi

sibi

lity

Non

-Wir

eles

sN

FMI

(Ear

to E

ar W

irel

ess)

Blue

toot

h 2.

4GH

z +

NFM

I

Product L R Push Button

Volume Wheel

Auto

Phone T-Coil Auto T Power Ultra Power

Connectivity Accessories

L R L R L R L R L R L R L R L R

IIC 10 Not Available Not Available

CIC 10 Not Available Not Available

CIC 10 Not Available Not Available

ITC 312 Not Available

HS (half shell)

312 Not Available

13 Not Available

FS (full shell)

312 Not Available

13 Not Available

HS (half shell)+

312 Not Available ConnectClip

Remote Control 3.0

TV Adapter 3.0

Phone Adapter 2.0

13 Not Available

FS (full shell)+

312 Not Available

13 Not Available

For Tinnitus SoundSupportTM, a push button and NFMI is necessary.+ Push button is required to activate Flight Mode

1732

1-12

222/3.

19

HZ: 250 500 1k 2k 3k 4k 6kAC Right

AC Left:

Your

Info

rmat

ion

Size+ Dexterity issues: make a true HS

+Unless requested otherwise, devices made as small as possible

Please send:

Return Impressions

Impression Boxes

Shipping Bags

New Cables

New Flex Strips

Airbills

Custom Product Forms

RITE Mold Forms

Service Order Forms

Special Instructions:

Internal use only

Do not write

Prod

uct O

ptio

nsO

ther

Opt

ions

1732

1-12

222/3.

19

Faceplate/Shell Color Canal Length(Factory select unless marked)

Vent Size (Factory select unless marked)

Beige/Beige (default) As marked Largest Possible

Light Brown/Light Brown Long (before 2nd bend) Extra Large 3.0

Medium Brown/Clear Short (before 1st bend) Large 2.4

Dark Brown/Clear Deep (at 2nd bend) Medium 1.4 Pressure

Black/Red or Blue (IIC Only) Medium (at 1st bend) Small 1.0 No Vent

Retention Removal Tactile Other

Canal Lock Removal Cord (Std IIC/CIC) Raised Push Button Name on Shell

Helix Lock Removal Notch Raised VC Wheel Color Dots

Soft Coat Matte Finish

Clothing Loop Other

1732

1-12

222/3.

19

Velox Custom Product Order Form | Reference Guide

Offering a full range of custom models andstyles for Opn 1, 2, 3 and Siya 1 and 2 there isa custom product for all your patient’s needs.

In addition to size and standard custom options, theVelox Custom Portfolio offers wireless and streamingchoices — including ear to ear wireless (NFMI) and earto ear wireless + Bluetooth (2.4 GHz).

Be sure to provide an impression with a full concha and helix area and a canal past the second bendregardless of the model selected.

Vents are calculated in Genie 2 unless otherwise specified in the “Vent Size” or “Special Instruction” sectionon the order form.

Invisibility Choose an IIC or CIC for optimaldiscreetness, offered asNon-Wireless models only.*

Warranty Terms Hearing devices include a repair warranty against defects in materials andworkmanship and a one-time replacement (service fee applies) for loss,theft, or damage according to the table on the right. Wireless Accessorieshave a one year repair warranty.

*Connectivity accessories, including remote control, are not available.

T-CapThe nano-coated,waxrepellent T-Cap filteris used for all miniaturecustom styles.

T-Cap (mic cover)Gray compact/Black toolsPart Number (1 pc):123328 - Beige123330 - Light Brown123331 - Med Brown123329 - Dark Brown123327 - Black

O-Cap (mic cover)Gray compact/Black toolsPart Number (1 pc):128003 - Beige128004 - Light Brown128005 - Med Brown128006 - Dark Brown

ProWax miniFitProviding advanced receiver port protection, the ProWax miniFit filter fits all styles in the new Oticon custom program.

ProWax miniFitGray “turtle”/Black tools Part Number (1 pc): 128057

(NFMI) Ear to Ear Wireless Choose a CIC, ITC, HS or FS for enabling binaural instrument communication, maximizing Oticon’s audiological features.*Wireless programming not available withNFMI only devices.

Bluetooth (2.4 GHz) + NFMI Choose a HS or FS for direct Bluetooth streaming to both ears and binaural instrument communication, fully compatible with all connectivity devices including ConnectClip, Remote Control 3.0, Phone Adapter 2.0, and TV Adapter 3.0. Free form openings, takesadvantage of space to ensure largest vent possible.

O-CapThe new nano-coated O-Capmicrophone protection filter isdesigned to reject wax and fitsall instruments using batterysize 312 and 13.

How to Choose:

Getting the Fit Right - It Starts with the Impression

Warranties

Accessories

Canal past second bend

Full Helix

Full Concha

Opn 1 3 year repair 2 year replacement

Opn 2 3 yeaer repair 2 year replacement

Opn 3 2 year repair 2 year replacement

Opn 4 2 year repair 2 year replacement

Opn5 2 year repair 2 year replacement

IIC CIC ITC ITE HS

ITE FS