hearusa wireless inium sense custom product order form - your hearing … · 2019-03-11 · inium...
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HearUSAWireless Inium Sense Custom Product Order Form
YHN Order Confirmation # (required when sending impressions): Impressions on file? yes no Order Date:
(All fields required)
HearUSA PO #:
Phone #:
Company Name:
Address 1:
Address 2:
City: State: Zip:
Today’s Date: Fitting Date:
Fitter’s Name:
Fitter’s E-mail:
First Name: Middle Init:
Last Name: Age:
Patient Information
Select Model: Alta2 Pro Alta2 Nera2 Pro Nera2 Ria2 Pro Ria2
Fitter’s InformationShip To Information
Submit this form to [email protected] or fax to 866-713-8258.
Your
Info
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ion
Wir
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Bill To #: 4001287
Battery Omni Only+ PB* VW Auto Phone
(not avail. w/ T-coil) T-coil Auto-T PowerŦ Ultra PowerŦ
L R L R L R L R L R L R L R L R L R
CIC 10 STD NA NA NA NA NA
ITC STD NA NA NA NANANA
Half Shell NA
Full Shell NA
IIC - Alta2 Pro
IIC - Nera2 Pro 10
IIC - Ria2 Pro
31210
31213
31213
10
* Push button serves as program change and T-coil access.
+ All models default to Directional Microphones unless Omni is selected.
Ŧ Technical information re 2cc coupler: Power Receiver: OSPL90 PK 121, PK Gain: 54, Ultra Power Receiver: OSPL90 PK 127, Pk Gain: 62
ConnectLineTM Options
Streamer Pro: Black White TV Adaptor Phone Adaptor ConnectLine MicRemote Control:
ITE Combination Controls for ITC 312, HS, FS or Ultra Power offers only 1 volume wheel (loudness) and 1 push button (program) for each binaural fitting. Select one option for each instrument desired.
Volume Wheel: Left Right
Push Button: Left Right
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Submit this form to [email protected] or fax to 866-713-8258.
Hz
AC L
AC R
250 500 1K 2K 3K 4K 6K
Audiometric Information (Required)
Return Impressions OK to make non-wireless for smaller size Substitutions may be made without calling
Please Send:
New Flex Strips New Cables Shipping Bags Custom Product Forms
RITE Mold Forms Impression Boxes Airbills Service Forms
Special Instructions:
Internal use only
Do not write
Pink 01 (default)Tan 02Medium Brown 03 faceplate/clear shell
Dark Brown 04 faceplate/clear shell
Clear Shell (specify faceplate color)
Pressure vent 1.0mm 1.4mm 2.4mm 3.0mm Free vent
IIC Colors:
Shell: Red/Blue (default)
Faceplate: Black (default)Clear Shell (specify faceplate color)
Venting: Vents are based on the calculation in Genie unless otherwise selected.
Options
Other Options
Faceplate/Shell Color
Colo
r/O
ptio
ns
(pink, tan, medium brown, dark brown, or black)
Canal Length: (Factory STD unless otherwise marked) Medium Long As marked
on impression
Canal LockRaised PBClothing LoopSpanish Instruction
Raised VWRemoval StringRemoval Notches
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Inium Sense Custom Product Order Form | Reference Guide
Please include your request on the comment line of the order form. Options available space permitting and may not be available on all models.
Vent
ing
Acce
ssor
ies
Cust
om O
ptio
n fo
r Sp
ecia
l Nee
ds
All vents are calculated in Genie, unless otherwise indicated on the order form. For a specific vent type please note it in special instructions.
Collection Vent Cone shape channel, round opening faceplate, “D’ opening on canal tip. Most common for ITC, HS, and FS where pressure vents not necessary.
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
ProWaxProviding advanced receiver port protection, the ProWax filter fits all styles in the new Oticon custom program.
ProWaxGray “turtle”/Lt Gray tools Part Number (1 pc): 123367
Cast Vent Straight channel through device. Round opening on faceplace and canal tip. Used when pressure vents are indicated.
Oval Vent Oval openings used for smaller instruments IIC and CIC.
Free Vent Free form openings, takes advantage 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.
Instrument Removal Options
Large BallReinforced
Removal Line Door Hook
Battery Indicator
Plastic Combo: Loop+removal string
VW Large, Small or Raised
Plastic: Small and Large
Helix LockCanal lock
Raised Push Button
Loops: Metal Small
and Large
Tactile Options
Clothing Loops
Retention Options Spiral Retention Ring
Submit this form to [email protected] or fax to 866-713-8258.
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