custom ear piece order form - phonakpro · 2020-02-17 · marvel™ custom ear piece order form...
TRANSCRIPT
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