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RIC/BTE Order FormEmail completed forms to [email protected]
Last Name:
First Name:
Age: Gender:
Patient Information HI Warranty/Rush Options
Notes:
2nd year 3rd year 4th year / 24-hour service ($59)
Customer Information
Ship To Account Number:
Address:
City: State: Zip:
Bill To Account Number:
Third Party Patient Number:
Date:
Purchase Order Number:
Contact Name:
Phone:
Email:
T7** Alpine White
Color Options — Venture
Phonak Bolero VPhonak Naída VPhonak Sky VPhonak CROS II
P1 Sand Beige
P2 Amber Beige
P3 Sandalwood
P4 Chestnut
P6 Silver Gray
P8 Velvet Black
P9* Ruby
Q1 Petrol
01 Beige
P5 Champagne
P7* Graphite Gray
Q2** Electric Green
Q3** Caribbean Pirate
T3** Precious Pink
M7** Blue Ocean
M6** Lava Red
M8** Majesty Purple *Not available for Sky V
**Also available on CROS II-13
Exclusive to Phonak Sky V
Color Options — Marvel™, Belong™
Phonak Audéo™ M/B Phonak Bolero™ M/BPhonak Sky™ M/BPhonak Naída™ BPhonak CROS B
H0/01 Beige
P6 Silver Gray
P8 Velvet Black
P5 Champagne
P7* Graphite Gray
T7 Alpine White
P1 Sand Beige
P3 Sandalwood
P4 Chestnut
*Not available for Sky M/B
**Also available on CROS B-13
Q2** Electric Green
Q3** Caribbean Pirate
T3** Precious Pink
M7** Blue Ocean
M6** Lava Red
M8** Majesty Purple
Exclusive to Phonak Sky M/B
Notes:
2
RIC/BTE Order Form
Venture
L RNaída V-RIC
o o Naída V90-RIC
o o Naída V70-RIC
o o Naída V50-RIC
o o Naída V30-RIC
Color: Color:L RSky V-RIC
o o Sky V90-RIC
o o Sky V70-RIC
o o Sky V50-RIC
Phonak RIC Models (Color options - see page 1)
Step 1: Select RIC Product
Marvel
L RAudéo M90
o o Audéo M90-312
o o Audéo M90-312T
o o Audéo M90-13T
o o Audéo M90-R
o o Audéo M90-RT
L RAudéo M70
o o Audéo M70-312
o o Audéo M70-312T
o o Audéo M70-13T
o o Audéo M70-R
o o Audéo M70-RT
L RAudéo M30
o o Audéo M30-312
o o Audéo M30-312T
o o Audéo M30-13T
o o Audéo M30-R
o o Audéo M30-RT
L RAudéo M50
o o Audéo M50-312
o o Audéo M50-312T
o o Audéo M50-13T
o o Audéo M50-R
o o Audéo M50-RT
Color: Color: Color:Color:
L RNaída B-R RIC
o o Naída B90-R RIC
o o Naída B70-R RIC
o o Naída B50-R RIC
Color:L RSky B-RIC
o o Sky B90-RIC
o o Sky B70-RIC
o o Sky B50-RIC
Color:
L RAudéo B90
o o Audéo B90-10
o o Audéo B90-312
o o Audéo B90-312T
o o Audéo B90-13
o o Audéo B90-R
Color:L RAudéo B70
o o Audéo B70-10
o o Audéo B70-312
o o Audéo B70-312T
o o Audéo B70-13
o o Audéo B70-R
Color:L RAudéo B50
o o Audéo B50-10
o o Audéo B50-312
o o Audéo B50-312T
o o Audéo B50-13
o o Audéo B50-R
Color:L RAudéo B30
o o Audéo B30-10
o o Audéo B30-312
o o Audéo B30-312T
o o Audéo B30-13
Color:
Belong
Step 2: Select Receiver (one per side)
*cShell Hard is required for these receivers
MarvelS (Standard)L Ro o 0 [054-0777/0778]o o 1 [054-0779/0780]o o 2 [054-0781/0782]o o 3 [054-0783/0784]
Belong/VenturexS (Standard)L Ro o 0 [054-0102/0103]o o 1 [054-0104/0105]o o 2 [054-0106/0107]o o 3 [054-0108/0109]
M (Medium)L Ro o 0 [054-0801/0802]o o 1 [054-0803/0804]o o 2 [054-0805/0806]o o 3 [054-0807/0808]
xP (Power)L Ro o 0 [054-0235/0236]o o 1 [054-0237/0238]o o 2 [054-0239/0240]o o 3 [054-0241/0242]
P (Power)L Ro o 0 [054-0812/0813]o o 1 [054-0814/0815]o o 2 [054-0816/0817]o o 3 [054-0818/0819]
UP (UltraPower)*Please use the Marvel Custom Ear Piece order form
xUP (UltraPower)* N/A with Audéo B 10
Please use the Belong or Venture Custom Ear Piece Order Form
3
RIC/BTE Order Form
Step 3: Select BTE ProductPhonak BTE Models (Color options – see page 1)
Color:L RBolero V90
o o Bolero V90-M
o o Bolero V90-P
o o Bolero V90-SP
Color:L RBolero V70
o o Bolero V70-M
o o Bolero V70-P
o o Bolero V70-SP
Color:L RBolero V50
o o Bolero V50-M
o o Bolero V50-P
o o Bolero V50-SP
Color:L RBolero V30
o o Bolero V30-M
o o Bolero V30-P
o o Bolero V30-SP
Color:L RNaída V90
o o Naída V90-SP
o o Naída V90-UP
Color:L RNaída V70
o o Naída V70-SP
o o Naída V70-UP
Color:L RNaída V50
o o Naída V50-SP
o o Naída V50-UP
Color:L RNaída V30
o o Naída V30-SP
o o Naída V30-UP
Color:L RSky V90
o o Sky V90-M
o o Sky V90-P
o o Sky V90-SP
o o Sky V90-UP
Color:L RSky V70
o o Sky V70-M
o o Sky V70-P
o o Sky V70-SP
o o Sky V70-UP
Color:L RSky V50
o o Sky V50-M
o o Sky V50-P
o o Sky V50-SP
o o Sky V50-UP
Venture
Belong
Color:L RSky B90
o o Sky B90-M
o o Sky B90-P
o o Sky B90-PR
o o Sky B90-SP
o o Sky B90-UP
Color:L RSky B70
o o Sky B70-M
o o Sky B70-P
o o Sky B70-PR
o o Sky B70-SP
o o Sky B70-UP
Color:L RSky B50
o o Sky B50-M
o o Sky B50-P
o o Sky B50-PR
o o Sky B50-SP
o o Sky B50-UP
Color: Color: Color: Color:L RNaída B90
o o Naida B90-SP
o o Naida B90-UP
L RNaída B70
o o Naida B70-SP
o o Naida B70-UP
L RNaída B50
o o Naida B50-SP
o o Naida B50-UP
L RNaída B30
o o Naida B30-SP
o o Naida B30-UP
Color:L RBolero B50
o o Bolero B50-M
o o Bolero B50-P
o o Bolero B50-PR
o o Bolero B50-SP
Color:L RBolero B90
o o Bolero B90-M
o o Bolero B90-P
o o Bolero B90-PR
o o Bolero B90-SP
Color:L RBolero B30
o o Bolero B30-M
o o Bolero B30-P
o o Bolero B30-SP
Color:L RBolero B70
o o Bolero B70-M
o o Bolero B70-P
o o Bolero B70-PR
o o Bolero B70-SP
Marvel
L R L R L RColor: Color: Color:
o o Sky M90-M
o o Sky M90-PR
o o Sky M70-M
o o Sky M70-PR
o o Sky M50-M
o o Sky M50-PR
Sky M90 Sky M70 Sky M50
L R L R L R L RColor: Color: Color: Color:
o o Bolero M90-M
o o Bolero M90-PR
o o Bolero M70-M
o o Bolero M70-PR
o o Bolero M50-M
o o Bolero M50-PR
o o Bolero M30-M
o o Bolero M30-PR
Bolero M90 Bolero M70 Bolero M50 Bolero M30
Step 4: Select SlimTube (5 per pack)
L Ro o 0 [054-0543/0539]
o o 1 [054-0544/0540]
o o 2 [054-0545/0541]
o o 3 [054-0546/0542]
L RBelong/Venture
L Ro o 00 [054-0884/0885]
o o 0 [054-0794/0795]
o o 1 [054-0796/0798]
o o 2 [054-0799/0823]
o o 3 [054-0824/0825]
L RMarvel
2019
-10 /
©So
nova
USA
Inc.
All
right
s re
serv
ed.
RIC/BTE Order Form
Sonova USA Inc. | 4520 Weaver Parkway | Warrenville, IL 60555 | Phone 800-777-7333 | Fax 630-393-9858 | www.phonakpro-us.com
Step 6: Wireless Accessories Marvel Belong/Ventureo TV Connector o ComPilot II/TVLink II Bundle o ComPilot Air II o DECT II
o Phonak PartnerMic™ o ComPilot Air II/RemoteMic Bundle o TVLink II o RemoteMic
o Phonak RemoteControl o ComPilot II o PilotOne II
Step 5: Select CROS Product
Color:L R
Phonak CROS II
o o CROS II-312 BTE
o o CROS II-13 BTE
Phonak CROS Models (Color options - see page 1)
Venture
Color:L Ro o CROS B-312 BTE
o o CROS B-13 BTE
o o CROS B-R BTE**Compatible with Audéo B-R only
Phonak CROS B
Belong
o o 0 [054-0690/0686]o o 1 [054-0691/0687]o o 2 [054-0692/0688]o o 3 [054-0693/0689]
Select CROS SlimTube:
L R
