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GOVERNMENT SERVICES RIC AND EARMOLD ORDER FORMTEL: (800) 955-4327 FAX: (732) 562-6653 EMAIL: [email protected]
Account #
Bill To Address: Contact: Ship To Address:
Tel:
P.O. No.Email:
Last Name, First Name, Middle Initial Patient Information
Last 4 S.S.#
Date: MM /DD / YY
Model Styletto™ Connect
Pure® Charge&Go Nx
Pure 312 Nx
Pure 13 Nx
CROS Pure Charge&Go Nx
CROS Pure 312 Nx
Hearing instrumentL R L R L R L R L R L R
RL RL RL RL RL RL
Battery Li-ion Li-ion 312 13 Li-ion 312
Program selector – Push button Rocker Rocker – –
Volume control – Push button Rocker Rocker Push button Rocker
Special instructions:
1
RIC Receiver Power Level
L R
S = 45/108dB RL
M = 60/119dB RL
P = 70/124dB RL
HP = 75/130dB* RL
*HP earmold only
2
Click Sleeves 2.0
L R
Vented xS RL
Vented S RL
Vented M RL
Vented L RL
Closed xS RL
Closed S RL
Closed M RL
Closed L RL
5a
RIC Receiver Tube Lengths
L R
0 RL
1 RL
2 RL
3 RL
4 (M receiver only) RL
3 Color
L R L R
Beige (1) RL Sandy Brown (31) RL
Granite (2) RL Dark Champagne (37) RL
Grey (3) RL Dark Granite (66) RL
Black (5) RL Deep Brown (72) RL
Silver (6) RL Black/Silver* RL
Pearl White (7) RL Cosmic Blue/Rose Gold* RL
Golden Blonde (30) RL Snow White/Rose Gold* RL
*Styletto Connect only
4
Click Domes
L R
Open 4mm RL
Open 8mm RL
Open 10mm RL
Semi-Open 8-12mm RL
Closed 6mm RL
Closed 8mm RL
Closed 10mm RL
Double 8-10mm RL
Double 10-12mm RL
5b
Accessories (Additional charge for accessories)
Streamline TV Streamline Mic miniPocket™
Li-Ion Portable power supply (Pure Charge&Go only)
6
Check if RIC Ordered with Earmolds
Shipping: No charge UPS 2nd DayEarmolds will ship with the RIC when ordered together
Hearing Thresholds250 Hz 500 Hz 1 kHz 2 kHz 3 kHz 4 kHz 6 kHz 8 kHz
Left
Right
RACHAP Active Duty
Indian Health Veterans Choice
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 #______________
Copyright © 2019 Signia GmbH. All rights reserved. Part #10536367 4/19 14.0 22B771 400 SI/19059-19
Earmold Style
L R
RIC
RL
Foil RIC RL
Embedded RIC (select receiver also) RL
Canal RIC RL
Half Shell RIC RL
Full Shell RIC RL
RIC with Lock
RL
Foil RIC with Lock RL
Embedded RIC with Lock RL
RIC Helix Lock RL
Canal RIC Lock RL
Skeleton RL
Semi-Skeleton RIC RL
3/4 Skeleton RIC RL
1/2 Skeleton RIC RL
Skeleton Foil RIC RL
Skeleton Open RIC RL
CROS RL
Material
Acrylic – hard RL
Silicone – soft (N/A for HP) RL
Matte or Gloss finish
Clear RL
Rose RL
Beige RL
Brown RL
Wax Options
HF4 RL
Extended Receiver TubingRL
Silicone with gloss finish(can swirl up to 3 colors)
L R
Red Opaque RL
Orange Opaque RL
Yellow Opaque RL
Blue Opaque RL
Lilac Opaque RL
Black Opaque RL
White Opaque RL
Pink Translucent RL
Blue Translucent RL
Purple Translucent RL
Red Glitter RL
Orange Glitter RL
Yellow Glitter RL
Green Glitter RL
Blue Glitter RL
Purple Glitter RL
Pink Glitter RL
Clear Glitter RL
Canal Length
Factory select option RL
Cut to Mark RL
Full length of impression RL
Venting
Largest Vent Possible RL
Semi-IROS RL
Select-a-Vent 3.0mm RL
Select-a-Vent 2.0mm RL
Standard 1.6mm RL
Pressure Vent 1.0mm RL
Power Vent 1.2mm RL
No Vent RL
Side Indicators(pick only 1 type)
L and R RL
Blue and Red dot RL
Removal String
Add Removal String RL
HP Earmold
HP Shell
Faceplate Color (HP Only)
Beige RL
Mocha RL
Brown RL
Shell Options and Coatings (HP Only)
Digital Canal Lock RL
Clear Coat RL
Red Shell RL
Blue Shell RL
Clear Shell RL
Venting (HP Only)
No Vent RL
Small SAV 1.6mm RL
Pressure Vent 1.3mm RL
Micro Vent 1.0mm RL
Wax Protection (HP Only)
L R
Bell Bore RL
Wax Spring RL
Extended Receiver Tubing RL
GOVERNMENT SERVICES RIC AND EARMOLD ORDER FORMTEL: (800) 955-4327 FAX: (732) 562-6653