Marvel™Custom Ear Piece Order Form

Ship To Account Number:

Address:

City: State: Zip:

Bill To Account Number:

Third Party Patient Number:

Date:

Purchase Order Number:

Contact Name:

Phone:

Email:

Last Name:

First Name:

Age: Gender:

Customer Information Patient Information

HI Warranty/Rush Options

2nd year 3rd year 4th year / 24-hour service ($59)Extended warranty not applicable for Sky Marvel

Technology Level M90 (Premium) M70 (Advanced) M50 (Standard) M30 (Essential, N/A Sky)

Hz 250 500 1K 2K 3K 4K

Left: AC

Right: AC

Audiogram (Required for AOV):

Hearing Device Selection — RIC Hearing Device Selection — BTE

Qty Instrument Type Instrument Style312 312T 13T R RT 1

_____ Phonak Audéo™ M

Qty Instrument Type Instrument StyleM PR (Available Fall 2019)

_____ Phonak Bolero™ M

_____ Phonak Sky™ MSpecify color choice:

Specify color choice:

Electric Green

Q2

CaribbeanPirate

Q3

Precious Pink

T3

Lava Red

M6

Blue Ocean

M7 M8

Majesty Purple

Exclusive to Phonak Sky M:

P1

Sand Beige

P3

Sandalwood

P4

Chestnut

P5

Champagne

P6

Silver Gray

P7

Graphite Gray2

P8

Velvet Black

H0

Beige

Colors

Alpine White

T7

2 Not available for Sky

Custom Ear Piece Selection — BTE

Side Shell Styles

L R

BTE SecureFit (Solid Silicone) [062-0007-01]

SlimTip (Hollow Acrylic) [062-0006-01]

SlimTube Length (00–3): L R

Custom Ear Piece Selection — RIC

Shell Styles Power LevelS46/111

M (Std.)50/114

P58/122

UP67/130

RIC SecureFit (Solid Silicone) [062-0007-01]

N/A

SlimTip (Hollow Acrylic) [062-0006-01]

N/A

SlimTip Titanium (Hollow) [062-0015-01]

N/A

cShell (Acrylic) [062-0008-01]

cShell Titanium [062-0009-01]

Receiver Length (0–3): L R

1 Audéo M-RT is only available in M90 level until Fall 2019

Special Instructions

027-

0535

-03/

2019

-08/

Prin

ted

in U

SA ©

Son

ova

USA

Inc.

All

righ

ts r

eser

ved.

Sonova USA Inc. | 4520 Weaver Parkway | Warrenville, IL 60555 | Phone 800-777-7333 | Fax 630-393-9858

Venting OptionsAOV (Audiogram

required)Pressure Vent 2.0mm SAV 2.5mm SAV 3.0mm SAV Customized

Large VentCavity Vent No Vent

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

RIC/BTE SecureFit (Silicone) N/A(Std.)

SlimTip (Acrylic) (Std.)

SlimTip Titanium(Std.)

cShell (Acrylic) N/A(Std.)

cShell Titanium N/A N/A

All of our products, including custom products and spare parts, can be ordered online in the Phonak store.

Sonova USA Inc. is not responsible and assumes no liability for any non-Phonak manufactured device or accessory sent by you to Phonak. Please ensure that you only include Phonak devices and accessories herein. Products, options and accessories are subject to change without notice.

Color Options(Titanium Shell: Gray / Faceplate: Black) Pink Tan Cocoa Brown Transparent Red Blue

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

cShell/SlimTip (Acrylic) – Shell Color

cShell (Acrylic) – Faceplate Color N/A N/A

Ear Piece Options

Phonak RemoteControl [076-0065-P5]

Phonak PartnerMic™ [076-4001-P511]

TV Connector [076-3006-0611]

Roger Select™ iN [056-3002-XX011]

Champagne [P5] Graphite Gray [P7]

Pearl White [W3]

Roger Pen™ iN [056-3003-XX]

Light Sterling [T4] Ruby [P9] Petrol [T5]

Roger Table Mic II iN [056-4001-P5011]

RIC Mini Charger Case [075-3009-11] N/A for Audéo M-RT

Power Pack [071-0003] Compatible with Charger Case Combi only

AccessoriesNo Wax

PreventionCerustop Extended

Receiver TubeWax Spring

L R L R L R L R

SlimTip (Acrylic)

SlimTip Titanium

cShell (Acrylic)

cShell Titanium

(Std.)

(Std.)

Wax Options

PreferencesIf necessary, may we change the following: Please CallYes No

UP to P OR P to M OR M to S if audiogram permits Build larger if required

(Std.)

(Std.)

Removal Line Color Options

L R

Transparent (Std.)

Tan/Pink

Brown/Cocoa

No Removal Line 4

3 The shell and lock will be the same color and not available for Titanium

Canal Lock 3

Skeleton Lock 3

Helix Lock 3

Extra Large 3

L R L R L R L R

RIC/BTE SecureFit (Silicone) N/A N/A

SlimTip (Acrylic) N/A

cShell (Acrylic)

Shell Options

4 No Removal Line is standard for cShell Titanium

L R

Extra Retention for Titanium Shells