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Audiogram Required for AOV
For Naida S Power SlimTube indicate tube size for left and right (see „Measure tube len gth“ 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 orde red earmoldIndicate whether you wish the BTE(s) to be delivered with the earmold(s)
Enter special wishes as neededSelect Rush Order option if required
Intertragal NotchOptimized Venting
Phonak CPS - Generic Custom Orderform March 2011
6
5
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 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.
Custom Earmold/Swim Plugs Order FormAdditional Information
ent/order detailsr delivery dat e
Audiogram Required for AOV
tails
Select Earmold Style and Options
ld style by ticking (L)left (R)right or (LR) for bothld canal lengthld materia l, color and lacquer options
ect tube type and color/ select connector type Power SlimTube indicate tube size for left and
„Measure tube len gth“ below)
audiogram for Acoustically Optimized Ventingically Optimized Vent is available for Spiceruments Only.
BTE Hearing Instrument Type
Instructions, needs, wishes
instrument to be fitted with the orde red
her you wish the BTE(s) to be delivered earmold(s)
ishes as neededect Rush Order option if required
Helix/Cymba
First Bend
Intertragal Notch
Ventilation BoreAOV Acoustically Optimized Venting
Sound Bore
Tragus
Crus
Concha Rim
Anti-Tragus
4
e a $45 charge will apply to all earmolds
Snap system is an easy exchangeable earmold onnector. Tube exchange was never so easy. No
and glueing just exchange the tube by a click!ages for the tube type and color options.
ctor QuickSnap (TLG)
Earmold areas ep 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
Please fill in client/order detailsEnter delivery dat e
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 materia l, 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 len gth“ 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 orde red 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
to
Naming of ear areas 0
Earmold Pricing (Private Pay)Earmold ordered with Phonak BTE Hearing Instrument: $50Earmold only: $50 (Plus regular shipping charges)Swim Plugs: $50 (Plus regular shipping charges)
Earmold WarrantyPhonak earmolds are guaranteed against defects in material or workmanship for one year. Remakes are free within 90 days of purchase. Phonak Swim Plugs have a 90 day warranty. Earmolds and Swim Plugs cannot be returned for credit. There is no loss and damage warranty on earmolds.
Connector QuickSnap The QuickSnap system is an easy exchangeable earmoldtube 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 colour options.
Earmold AreasNaming of ear areas
Swim Plug ColoursEarmold Colours
www.phonakpro.ca
Blue (07) Red (10) Green (17)
Yellow (20) Pink (26) Light Blue (34)
Custom Earmold/SwimPlugs Cover Sheet April 2016.indd 1 2017-03-13 2:48 PM
Prelocked Tubing Standard for all soft earmolds
Green (17) White (19) Yellow (20) Pink (26)
Blue (07) Purple (08) Red (10) Orange (11)
Clear/Transparent (21)
Rose Tint (T) Transparent Brown (N)
Black (06)
Audiogram Required for AOV
For Naida S Power SlimTube indicate tube size for left and right (see „Measure tube len gth“ 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 orde red earmoldIndicate whether you wish the BTE(s) to be delivered with the earmold(s)
Enter special wishes as neededSelect Rush Order option if required
Intertragal NotchOptimized Venting
Phonak CPS - Generic Custom Orderform March 2011
6
5
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 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.
Custom Earmold/Swim Plugs Order FormAdditional Information
ent/order detailsr delivery dat e
Audiogram Required for AOV
tails
Select Earmold Style and Options
ld style by ticking (L)left (R)right or (LR) for bothld canal lengthld materia l, color and lacquer options
ect tube type and color/ select connector type Power SlimTube indicate tube size for left and
„Measure tube len gth“ below)
audiogram for Acoustically Optimized Ventingically Optimized Vent is available for Spiceruments Only.
BTE Hearing Instrument Type
Instructions, needs, wishes
instrument to be fitted with the orde red
her you wish the BTE(s) to be delivered earmold(s)
ishes as neededect Rush Order option if required
Helix/Cymba
First Bend
Intertragal Notch
Ventilation boreAOV Acoustically Optimized Venting
Sound bore
Tragus
Crus
Concha rim
Anti-Tragus
4
e a $45 charge will apply to all earmolds
Snap system is an easy exchangeable earmold onnector. Tube exchange was never so easy. No
and glueing just exchange the tube by a click!ages for the tube type and color options.
ctor QuickSnap (TLG)
Earmold areas ep 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
Please fill in client/order detailsEnter delivery dat e
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 materia l, 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 len gth“ 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 orde red 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
to
Naming of ear areas 0
Earmold Pricing (Private Pay)Earmold ordered with Phonak BTE Hearing Instrument: $50Earmold only: $50 (Plus regular shipping charges)Swim Plugs: $50 (Plus regular shipping charges)
Earmold WarrantyPhonak earmolds are guaranteed against defects in material or workmanship for one year. Remakes are free within 90 days of purchase. Phonak Swim Plugs have a 90 day warranty. Earmolds and Swim Plugs cannot be returned for credit. There is no loss and damage warranty on earmolds.
Connector QuickSnapThe QuickSnap system is an easy exchangeable earmoldtube with connector. Tube exchange was never so easy. No more drilling and glueing just exchange the tube by a click!Refer to the order form for the tube type and colour options.
Earmold AreasNaming of ear areas
Swim Plug ColoursEarmold Colours
www.phonakpro.ca
Blue (07) Red (10) Green (17)
Yellow (20) Pink (26) Light Blue (34)
Custom Earmold/SwimPlugs Cover Sheet April 2016.indd 1 2017-03-13 2:48 PM
Prelocked Tubing Standard for all soft earmolds
Audiogram Required for AOV
For Naida S Power SlimTube indicate tube size for left and right (see „Measure tube len gth“ 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 orde red earmoldIndicate whether you wish the BTE(s) to be delivered with the earmold(s)
Enter special wishes as neededSelect Rush Order option if required
Intertragal NotchOptimized Venting
Phonak CPS - Generic Custom Orderform March 2011
6
5
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 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.
Custom Earmold/Swim Plugs Order FormAdditional Information
ent/order detailsr delivery dat e
Audiogram Required for AOV
tails
Select Earmold Style and Options
ld style by ticking (L)left (R)right or (LR) for bothld canal lengthld materia l, color and lacquer options
ect tube type and color/ select connector type Power SlimTube indicate tube size for left and
„Measure tube len gth“ below)
audiogram for Acoustically Optimized Ventingically Optimized Vent is available for Spiceruments Only.
BTE Hearing Instrument Type
Instructions, needs, wishes
instrument to be fitted with the orde red
her you wish the BTE(s) to be delivered earmold(s)
ishes as neededect Rush Order option if required
Helix/Cymba
First Bend
Intertragal Notch
Ventilation BoreAOV Acoustically Optimized Venting
Sound Bore
Tragus
Crus
Concha Rim
Anti-Tragus
4
e a $45 charge will apply to all earmolds
Snap system is an easy exchangeable earmold onnector. Tube exchange was never so easy. No
and glueing just exchange the tube by a click!ages for the tube type and color options.
ctor QuickSnap (TLG)
Earmold areas ep 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
Please fill in client/order detailsEnter delivery dat e
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 materia l, 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 len gth“ 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 orde red 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
to
Naming of ear areas 0
Earmold Pricing (Private Pay)Earmold ordered with Phonak BTE Hearing Instrument: $50Earmold only: $50 (Plus regular shipping charges)Swim Plugs: $50 (Plus regular shipping charges)
Earmold WarrantyPhonak earmolds are guaranteed against defects in material or workmanship for one year. Remakes are free within 90 days of purchase. Phonak Swim Plugs have a 90 day warranty. Earmolds and Swim Plugs cannot be returned for credit. There is no loss and damage warranty on earmolds.
Connector QuickSnap The QuickSnap system is an easy exchangeable earmoldtube 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 colour options.
Earmold AreasNaming of ear areas
Swim Plug ColoursEarmold Colours
www.phonakpro.ca
Blue (07) Red (10) Green (17)
Yellow (20) Pink (26) Light Blue (34)
Custom Earmold/SwimPlugs Cover Sheet April 2016.indd 1 2017-03-13 2:48 PM
Prelocked Tubing Standard for all soft earmolds
Earmold Colours Swim Plug Colours
(TRS)
Step 5 Earmold/Swim Plug Materials Step 6 Tube/Connector Details
Step 2 Order Details Step 3 Select Earmold Style Step 4 Select Canal Length/ Venting
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. P5)
c R Model: _____________________ R Colour Code: ___________(eg. P5)
OR c Earmold only (Private Pay $50 each)
(Plus regular shipping charges) Please also send me the following accessories:__________________________________
__________________________________OR c Swim Plugs (Private Pay $50 each)
(For Swim Plugs please go to Step 5)
Custom Earmold/Swim Plug Order Form
Ship to Account Number:
Bill to Account Number: Phone#:Company Name:Address:Contact Name (Audiologist/Dispenser):Claim mVAC/RCMP/DND mHC (NIHB) mREGIE (RAMQ) mCSST mWSIB (ON) mWorkSafeBC
mWCB Alberta mWCB Manitoba mWCB Sask mWCB Yukon mWHSCC (NL, WSNB, WCB PEI) mEastern Health mODSP mAADL mOther: _____________
User Name: Last ccccccccccc
First cccccccccccm Pediatric Date of Birth:______ / _______ / _______ DD MM Year
Claim # (Required):
Changes can not be made without calling
(Please print)
025-
0574
Pho
nak
Cust
om E
arm
old/
Swim
Plu
g Or
der
Form
Mar
ch 2
021
Form
27_
V13
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
Date : ______ / _______ / _______ DD MM Year
PO#: _______________________
Attention to (at Phonak): ________________________________
S
S
Canal LengthLeft c Short c Med. c LongRight c Short c Med. c Long
Ear Texturec Soft c Avg. c Firm
Colour
Swim Plug Materials Blue
(07)
Red
(10)
Gree
n (1
7)
Yello
w (2
0)
Pink
(26)
Ligh
t Bl
ue
(34)
Floatable Silicone c L c R c L c R c L c R c L c R c L c R c L c R c L c R
c Please indicate if Swim Plug is for a Lyric wearer*Not available with Prelocked tubing
250 500 1K 2K 3K 4K
Speech Scores
p dB HL p dB SPL
L
R
c AOV Acoustically Optimized Vent (Audiogram Required)
OR c Vent Size: Customer Specified:
c L ______ c R ______
Tube/Connector details Sl
im t
ube
leng
th
13 Medium Tube (13M)* c L c R NA
13 Thick Wall Tube (13T) c L c R NA
13 Dry Wall Tube (13D)* c L c R NA
13 Dry Thick Wall Tube (13W) c L c R NA
SlimTube (STA) Bolero B length 0/1/2/3 L R
SDS 4.0 Naida P, Naída M & Sky M length 00/0/1/2/3 L R
Power SlimTube II (PS2) Naída B, Sky B (SP & UP models only) length 0/1/2/3
L RS
S
S
S
Colour Lacquer
Earmold Materials Clea
r/Tr
ansp
aren
t (2
1)
Rose
Tin
t (T)
Brow
n/Tr
ansp
aren
t (N
)
Blac
k (0
6)
Blue
(07)
Purp
le (0
8)
Red
(10)
Ora
nge
(11)
Gre
en (1
7)
Whi
te (1
9)
Yello
w (2
0)
Pink
(26
)
Glos
sy F
inis
h
No
Lacq
uer (
clea
r onl
y)
Acrylic hard (lucite) cL cR S O O NA NA NA NA NA NA NA NA NA S O
Silicone soft 70 cL cR S O O O O O O O O O O O S NA
Silicone very soft 40 cL cR S O O O O O O O O O O O S NA
Soft earmolds come standard with prelocked tubing (TRS)
Hard earmolds come standard with glued tubing
Tube/Connectors are only available in clear/transparent
Phone: 905-677-1167 or 1-800-876-1167 Fax: 905-677-7536 or 1-800-814-5799c Standard c Optional S O
Type:
Step 1 General Information
Step 7 Special Instructions
__________________________________________________________________________________________________________________________________________________________________________________________
13M is standard for acrylic and 13T is standard for silicone
Recommended