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Phonak Custom Earmold Order FormAdditional Information
Please fill in client/order detailsEnter delivery date
Audiogram Required for AOV
Order Details
Select Earmold Style and Options
Select earmold style by ticking (L)left (R)right or (LR) for bothSelect earmold canal lengthSelect earmold material, color and lacquer optionsSelect tube type and color/ select connector typeFor Naida S Power SlimTube indicate tube size for left and right (see „Measure tube length“ below)
Enter patient audiogram for Acoustically Optimized VentingAOV Acoustically Optimized Vent is available for Spice Hearing Instruments Only.
Specify BTE Hearing Instrument Type
Special Instructions, needs, wishes
Indicate the instrument to be fitted with the ordered earmoldIndicate whether you wish the BTE(s) to be delivered with the earmold(s)
Enter special wishes as neededSelect Rush Order option if required
Helix/Cymba
First Bend
Intertragal Notch
Ventilation boreAOV Acoustically Optimized Venting
Sound bore
Tragus
Crus
Concha rim
Anti-Tragus
6
5
4321
7
Please Note a $45 charge will apply to all earmolds
The QuickSnap system is an easy exchangeable earmold tube with connector. Tube exchange was never so easy. No more drilling and glueing just exchange the tube by a click!See the order pages for the tube type and color options.
Connector QuickSnap (TLG)
Earmold areas Step by Step Order entry
Measure tube length (Power SlimTube)
Use Phonaks’ measurement tool to identify the corresponding tube length (00/0/1/2/3).The picture below shows the required tube length. For this ear size „1"would need to be ordered
Naming of ear areas 0
Custom Earmold with AOV Order FormAdditional Information
Please fill in client/order detailsEnter delivery date
Audiogram Required for AOV
Order Details
Select Earmold Style and Options
Select earmold style by ticking (L)left (R)right or (LR) for bothSelect earmold canal lengthSelect earmold material, color and lacquer optionsSelect tube type and color/ select connector typeFor Naida S Power SlimTube indicate tube size for left and right (see „Measure tube length“ below)
Enter patient audiogram for Acoustically Optimized Venting
Specify BTE Hearing Instrument Type
Special Instructions, needs, wishes
Indicate the instrument to be fitted with the ordered earmoldIndicate whether you wish the BTE(s) to be delivered with the earmold(s)
Enter special wishes as neededSelect Rush Order option if required
Helix/Cymba
First Bend
Intertragal Notch
Ventilation boreAOV Acoustically Optimized Venting
Sound bore
Tragus
Crus
Concha rim
Anti-Tragus
Phonak CPS - Generic Custom Orderform March 2011
6
5
4321
7
The QuickSnap system is an easy exchangeable earmold tube with connector, for use with thick wall tubing only. Tube exchange was never so easy. No more drilling and glueing just exchange the tube by a click! See the order pages for the tube type and color options
Connector QuickSnap
Earmold areas Step by Step Order entry
Measure tube length (Power SlimTube) Naida S only
Use Phonak’s measurement tool to identify the corresponding tube length (00/0/1/2/3).The picture below shows the required tube length. For this ear size “1” would need to be ordered.
Naming of ear areas 0
Earmold Pricing (Private Pay)Earmold ordered with Phonak BTE Hearing Instrument: $50Earmold only: $50
Earmold Warranty:Phonak earmolds are guaranteed against defects in material or workmanship for one year. Remakes are free within 90 days of purchase. Earmolds cannot be returned for credit. There is no loss and damage warranty on earmolds.
Connector QuickSnap (TLG) The QuickSnap system is an easy exchangeable earmold tube with connector. Tube exchange was never so easy. No more drilling and glueing just exchange the tube by a click! See the order pages for the tube type and color options.
Earmold areasNaming of ear areas
Measure tube length (Power SlimTube) Use Phonaks’ measurement tool to identify the correspond-ing tube length (00/0/1/2/3). The picture to the right shows the required tube length. For this ear size “1” would need to be ordered
Custom Earmold with AOV Order FormAdditional Information
Please fill in client/order detailsEnter delivery date
Audiogram Required for AOV
Order Details
Select Earmold Style and Options
Select earmold style by ticking (L)left (R)right or (LR) for bothSelect earmold canal lengthSelect earmold material, color and lacquer optionsSelect tube type and color/ select connector typeFor Naida S Power SlimTube indicate tube size for left and right (see „Measure tube length“ below)
Enter patient audiogram for Acoustically Optimized Venting
Specify BTE Hearing Instrument Type
Special Instructions, needs, wishes
Indicate the instrument to be fitted with the ordered earmoldIndicate whether you wish the BTE(s) to be delivered with the earmold(s)
Enter special wishes as neededSelect Rush Order option if required
Helix/Cymba
First Bend
Intertragal Notch
Ventilation boreAOV Acoustically Optimized Venting
Sound bore
Tragus
Crus
Concha rim
Anti-Tragus
Phonak CPS - Generic Custom Orderform March 2011
6
5
4321
7
The QuickSnap system is an easy exchangeable earmold tube with connector, for use with thick wall tubing only. Tube exchange was never so easy. No more drilling and glueing just exchange the tube by a click! See the order pages for the tube type and color options
Connector QuickSnap
Earmold areas Step by Step Order entry
Measure tube length (Power SlimTube) Naida S only
Use Phonak’s measurement tool to identify the corresponding tube length (00/0/1/2/3).The picture below shows the required tube length. For this ear size “1” would need to be ordered.
Naming of ear areas 0
www.phonakpro.ca
Prelocked Tubing (TRS) For all soft earmolds
Step 1 Order Details Step 2 Select Earmold Style Step 3 Select Canal Length
Select whether you wish the BTE(s) to be delivered with the earmold(s) or send earmold(s) only. c Earmold (Private Pay $50 each) sent with
BTE Hearing Instrument c L Model: _____________________ L Colour Code: ___________(eg. F5)
c R Model: _____________________ R Colour Code: ___________(eg. F5)
OR c Earmold only (Private Pay $50 each) Please also send me the following accessories:
__________________________________
__________________________________
__________________________________
Our default configurations§ Acrylic hard transparent§ 13 Medium Tube§ Medium Canal Length
Step 4 Earmold Materials Step 5 Tube/Connector Details
Step 6 Venting Step 7 Special Instructions
Audiogram (Required for AOV) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Phonak Custom Earmold Order Form Phone: 905-677-1167 or 1-800-876-1167 Fax: 905-677-7536 or 1-800-814-5799
Ship to Account Number:
Bill to Account Number: Phone#:
Company Name:Address:Contact Name (Audiologist/Dispenser):Claim Type: mVAC/NIHB/RCMP mWCB-AB mWS-BC mWCB-MB mWSIB
mCSST mREGIE mOther: ____________________________
Client Information M c F c
User Name: Last ccccccccccc
First cccccccccccmPaediatric Date of Birth:______ / _______ / _______ DD MM Year
Claim # (Required): ccccccccccc
Changes may be made without calling
Right Left Binaural
SRT
MCL
UCL 250 500 1K 2K 3K 4K
Speech Scores
p dB HL p dB SPLL
R
(Please print)
025-
0574
Pho
nak
Cust
om E
arm
old
Ord
er F
orm
Nov
embe
r 20
12 F
orm
27
S: Standard configuration
Colour Lacquer Finish
Earmold materials Clea
r/Tr
ansp
aren
t (2
1)
Rose
Tin
t (T
)
Tran
spar
ent
Brow
n (N
)
Lacq
uer
Acry
lic h
ard/
soft
- G
loss
y fin
ish
Lacq
uer
Acry
lic h
ard
- M
att
finis
h
Acrylic hard (lucite) c L c R S S
Silicone soft 70* c L c R S NA NA S NA
Silicone very soft 40* c L c R S NA NA S NA
Canal Moldc L c R
Canal Lockc L c R
Helix Lockc L c R
Semi Skeletonc L c R
Skeletonc L c R
Carved Half Shellc L c R
Carved Full Shellc L c R
Full Shellc L c R
ID: Inner Diameter OD: Outer Diameter * Transparent tube only
Colour Con.
Tube/Connector details
Air
tube
leng
th
Clea
r/Tr
ansp
aren
t (2
1)
Rose
Tin
t (M
4)
Tran
spar
ent
Brow
n (L
7)
Conn
ecto
r Q
uick
Snap
(TLG
)
00/0/1/2/3
13 Medium Tube (ID 1.9, OD 3.2) 13M c L c R NA S
13 Thick Wall Tube (ID 1.9, OD 3.3) 13T c L c R NA
13 Dry Wall Tube (ID 1.9, OD 3.2) 13D c L c R NA *13 Dry Thick Wall Tube (ID 1.9, OD 3.3) 13W c L c R NA *Power SlimTube Naida S only (ID 1.4, OD 2.0) PST NA NA NAL R
Date : ______ / _______ / _______ DD MM Year
c Rush order in 48h ($39.00 charge)
PO#: _______________________
Attention to (at Phonak): ________________________________
c AOV Acoustically Optimized Vent (Quest & Spice+ Hearing Instruments Only)
OR
c Vent Size: Customer Specified: c L ______ c R ______
SS
Canal LengthLeft c Short c Med. c LongRight c Short c Med. c Long
Ear Texturec Soft c Avg. c Firm
*Soft earmolds come standard with prelocked tubing (TRS)