Step by Step Order entry Earmold areas Custom Earmold/Swim ... · Enter special wishes as needed Select Rush Order option if required Intertragal Notch Optimized Venting Phonak CPS

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


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


Order Details


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)






Helix/Cymba

First Bend

Intertragal Notch

Ventilation boreAOV Acoustically Optimized Venting

Sound bore

Tragus

Crus

Concha rim

Anti-Tragus


6

5

4321

7


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)










6

5

7







tails











Helix/Cymba

First Bend

Intertragal Notch


Sound bore

Tragus

Crus

Concha rim

Anti-Tragus

4








Naming of ear areas



Order Details








Helix/Cymba

First Bend

Intertragal Notch


Sound bore

Tragus

Crus

Concha rim

Anti-Tragus


6

5

4321

7


Connector QuickSnap




to




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.



www.phonakpro.ca














6

5

7







tails











Helix/Cymba

First Bend

Intertragal Notch

Ventilation BoreAOV Acoustically Optimized Venting

Sound Bore

Tragus

Crus

Concha Rim

Anti-Tragus

4








Naming of ear areas



Order Details








Helix/Cymba

First Bend

Intertragal Notch


Sound bore

Tragus

Crus

Concha rim

Anti-Tragus


6

5

4321

7


Connector QuickSnap




to




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.



www.phonakpro.ca





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

Documents

Step by Step Order entry Earmold areas Custom Earmold/Swim ... · Enter special wishes as needed Select Rush Order option if required Intertragal Notch Optimized Venting Phonak CPS