government agencies earmold and ric order · pdf filepink translucent clear glitter ... open...
TRANSCRIPT
Check if RIC Ordered with Earmolds
Shipping: No charge FedEx OvernightGroundEarmolds will ship with the BTE when ordered together
GOVERNMENT AGENCIES EARMOLD AND RIC ORDER FORM
Hearing Thresholds250 Hz 500 Hz 1 kHz 2 kHz 3 kHz 4 kHz 6 kHz 8 kHz
L
R
TEL: (800) 955-4327 FAX: (732) 562-6653
P.O. No.
Account #
Last Name, First Name, Middle Initial Client Information
Bill To Address: Contact: Ship To Address:
Tel:
Email:
Last 4 S.S.#
Date: MM /DD / YY
Color L R L R
Matte or Gloss finishClear BeigeRose Brown
Silicone with gloss finish – can swirl up to 3 colorsRed Opaque Blue TranslucentOrange Opaque Purple TranslucentYellow Opaque Red GlitterGreen Opaque Orange GlitterBlue Opaque Yellow GlitterLilac Opaque Green GlitterBlack Opaque Blue GlitterWhite Opaque Purple GlitterGreen Translucent Pink GlitterPink Translucent Clear Glitter
Skeleton Foil RIC Skeleton Open RIC Skeleton OpenSkeleton Foil RIC Skeleton Open RIC Skeleton OpenStyle RIC RIC Lock
Foil RIC
Foil RIC with Lock
Canal RIC
RIC Helix Lock
Canal Lock RIC
Half Shell RIC
Full Shell RIC
Skeleton RIC
Semi- Skeleton
RIC
3/4 Skeleton
RIC
1/2 Skeleton
RIC
Skeleton Foil RIC
Skeleton Open
RICReceiver gain L R L R L R L R L R L R L R L R L R L R L R L R L R L R L R
S miniReceiver 2.0M miniReceiver 2.0P miniReceiver 2.0MaterialAcrylic (Hard)Silicone (Soft)FinishMatteGlossVentingLargest Vent PossibleOpen Air Vent 1
Semi-IROSSelect-a-Vent 3.0mmSelect-a-Vent 2.0mmStandard 1.6mmPressure Vent 1.0mmPower Vent 1.2mmNo VentRemoval stringAdd Removal String 2
Canal lengthDeepLongMediumShortCut to MarkFull Length of ImpressionSide Indicators (pick only 1 type)L and RBlue and Red dot
Special instructions:
Warranty 36-Month, no charge.
Click Domes for RICsopen L 4 mm 8 mm 10 mm
R 4 mm 8 mm 10 mm semi-open L 8-12 mm
R 8-12 mm closed L 6 mm 8 mm 10 mm
R 6 mm 8 mm 10 mm double L 8-10 mm 10-12 mm
R 8-10 mm 10-12 mm
Click Sleeves 2.0 for RICsVented L xS S M L
R xS S M L Closed L xS S M L
R xS S M L
For internal use only
Aids: 1 2 Earmolds: 1 2 Impression: Yellow Blue Pink Peach White Purple Trans Brown Turq Green Org
Receiver: 1 2 Impressions: 1 2
Charger: 1 2 Remotes: 1 2 RECEIVED = NJ Bag #______________ ID #______________
BTE AccessoriesRemote Control Options
miniPocket™ 5 easyTek W/ transmitter 5 VoiceLink™ 6
easyTek™ 5 easyPocket™ 5
Chargers
Pure 7px Carat 7bx
TV
Streamline TV 7 TV Transmitter 8
Power Supply
Cellion Portable Power Supply 9
(5) primax and binax (6) requires easyTek for primax/binax (7) Pure 13 BT only (8) primax only (9) Cellion only
Choose Product L RPure 13 BT px – 75 dBPure px – 75 dBCarat px – 75 dBCellion px – 75 dB
Faceplate Color L RBeigeMochaBrown
HP – Receiver LengthL 0 1 2 3 R 0 1 2 3
Canal Length L RDeepLongAs Marked
Shell Options and Coatings L RCanal LockClear CoatRemoval StringRed ShellBlue ShellClear ShellDeep Red Shell (primax only)
Wax Protection Options L RBell BoreWax SpringHF4 PROExtended Receiver Tubing
Venting L R(Medium vent or smaller is recommended for directional models) No VentSmall SAV (1.6mm)Pressure Vent (1.3mm)Micro Vent (1.0mm)
RIC BTE with HP Earmold
Carat 7 primax Gain LengthL S / 45 n M / 60 n P / 70 n 0 1 2 3 4 *
R S / 45 n M / 60 n P / 70 n 0 1 2 3 4 *
Pure® 7 primax Gain LengthL S / 45 n M / 60 n P / 70 n 0 1 2 3 4 *
R S / 45 n M / 60 n P / 70 n 0 1 2 3 4 *
Cellion® 7 primax Gain LengthL S / 45 n M / 60 n P / 70 n 0 1 2 3 4 *
R S / 45 n M / 60 n P / 70 n 0 1 2 3 4 *
CROS PureL
R CROS only available for Pure primax
GOVERNMENT AGENCIES EARMOLD AND RIC ORDER FORM
Copyright © 2017 Signia GmbH. Sivantos, Inc. is a Trademark Licensee of Siemens AG. Part #10536367 10/17 11.0 22B771 860 SI/18079-17
*4 length offered on M receiver
L R
Description Color #
Pure 13 BT primax
Pure primax & CROS
Pure
Carat primax
Cellion primax
Beige 1
Granite 2
Grey 3
Brown 4
Black 5
Silver 6
Pearl White 7
Golden Blonde 30
Sandy Brown 31
Dark Champagne 37
Dark Granite 66
Deep Brown 72
Deep Red 73
Spirit C5
L RAdd/Replace elbow/anchorAdd/Replace removal option
Remake*
remake allowed within 180 days of original invoice date. *Charges may apply.
Reason for remake:L R
Too tightToo looseManufacturer error
Earmold Serial Number
L
R
Earmold Repair & Remake
Charger included
Pure® 13 BT primax Gain LengthL S / 45 n M / 60 n P / 70 n 0 1 2 3 4 *
R S / 45 n M / 60 n P / 70 n 0 1 2 3 4 *