Check if RIC Ordered with Earmolds

Shipping: No charge FedEx OvernightGroundEarmolds will ship with the BTE when ordered together

GOVERNMENT AGENCIES EARMOLD AND RIC ORDER FORM

Hearing Thresholds250 Hz 500 Hz 1 kHz 2 kHz 3 kHz 4 kHz 6 kHz 8 kHz

L

R

TEL: (800) 955-4327 FAX: (732) 562-6653

P.O. No.

Account #

Last Name, First Name, Middle Initial Client Information

Bill To Address: Contact: Ship To Address:

Tel:

Email:

Last 4 S.S.#

Date: MM /DD / YY

Color L R L R

Matte or Gloss finishClear BeigeRose Brown

Silicone with gloss finish – can swirl up to 3 colorsRed Opaque Blue TranslucentOrange Opaque Purple TranslucentYellow Opaque Red GlitterGreen Opaque Orange GlitterBlue Opaque Yellow GlitterLilac Opaque Green GlitterBlack Opaque Blue GlitterWhite Opaque Purple GlitterGreen Translucent Pink GlitterPink Translucent Clear Glitter

Skeleton Foil RIC Skeleton Open RIC Skeleton OpenSkeleton Foil RIC Skeleton Open RIC Skeleton OpenStyle RIC RIC Lock

Foil RIC

Foil RIC with Lock

Canal RIC

RIC Helix Lock

Canal Lock RIC

Half Shell RIC

Full Shell RIC

Skeleton RIC

Semi- Skeleton

RIC

3/4 Skeleton

RIC

1/2 Skeleton

RIC

Skeleton Foil RIC

Skeleton Open

RICReceiver gain L R L R L R L R L R L R L R L R L R L R L R L R L R L R L R

S miniReceiver 2.0M miniReceiver 2.0P miniReceiver 2.0MaterialAcrylic (Hard)Silicone (Soft)FinishMatteGlossVentingLargest Vent PossibleOpen Air Vent 1

Semi-IROSSelect-a-Vent 3.0mmSelect-a-Vent 2.0mmStandard 1.6mmPressure Vent 1.0mmPower Vent 1.2mmNo VentRemoval stringAdd Removal String 2

Canal lengthDeepLongMediumShortCut to MarkFull Length of ImpressionSide Indicators (pick only 1 type)L and RBlue and Red dot

Special instructions:

Warranty 36-Month, no charge.

Click Domes for RICsopen L 4 mm 8 mm 10 mm

R 4 mm 8 mm 10 mm semi-open L 8-12 mm

R 8-12 mm closed L 6 mm 8 mm 10 mm

R 6 mm 8 mm 10 mm double L 8-10 mm 10-12 mm

R 8-10 mm 10-12 mm

Click Sleeves 2.0 for RICsVented L xS S M L

R xS S M L Closed L xS S M L

R xS S M L

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 #______________

BTE AccessoriesRemote Control Options

miniPocket™ 5 easyTek W/ transmitter 5 VoiceLink™ 6

easyTek™ 5 easyPocket™ 5

Chargers

Pure 7px Carat 7bx

TV

Streamline TV 7 TV Transmitter 8

Power Supply

Cellion Portable Power Supply 9

(5) primax and binax (6) requires easyTek for primax/binax (7) Pure 13 BT only (8) primax only (9) Cellion only

Choose Product L RPure 13 BT px – 75 dBPure px – 75 dBCarat px – 75 dBCellion px – 75 dB

Faceplate Color L RBeigeMochaBrown

HP – Receiver LengthL 0 1 2 3 R 0 1 2 3

Canal Length L RDeepLongAs Marked

Shell Options and Coatings L RCanal LockClear CoatRemoval StringRed ShellBlue ShellClear ShellDeep Red Shell (primax only)

Wax Protection Options L RBell BoreWax SpringHF4 PROExtended Receiver Tubing

Venting L R(Medium vent or smaller is recommended for directional models) No VentSmall SAV (1.6mm)Pressure Vent (1.3mm)Micro Vent (1.0mm)

RIC BTE with HP Earmold

Carat 7 primax Gain LengthL S / 45 n M / 60 n P / 70 n 0 1 2 3 4 *

R S / 45 n M / 60 n P / 70 n 0 1 2 3 4 *

Pure® 7 primax Gain LengthL S / 45 n M / 60 n P / 70 n 0 1 2 3 4 *

R S / 45 n M / 60 n P / 70 n 0 1 2 3 4 *

Cellion® 7 primax Gain LengthL S / 45 n M / 60 n P / 70 n 0 1 2 3 4 *

R S / 45 n M / 60 n P / 70 n 0 1 2 3 4 *

CROS PureL

R CROS only available for Pure primax

GOVERNMENT AGENCIES EARMOLD AND RIC ORDER FORM

Copyright © 2017 Signia GmbH. Sivantos, Inc. is a Trademark Licensee of Siemens AG. Part #10536367 10/17 11.0 22B771 860 SI/18079-17

*4 length offered on M receiver

L R

Description Color #

Pure 13 BT primax

Pure primax & CROS

Pure

Carat primax

Cellion primax

Beige 1

Granite 2

Grey 3

Brown 4

Black 5

Silver 6

Pearl White 7

Golden Blonde 30

Sandy Brown 31

Dark Champagne 37

Dark Granite 66

Deep Brown 72

Deep Red 73

Spirit C5

L RAdd/Replace elbow/anchorAdd/Replace removal option

Remake*

remake allowed within 180 days of original invoice date. *Charges may apply.

Reason for remake:L R

Too tightToo looseManufacturer error

Earmold Serial Number

L

R

Earmold Repair & Remake

Charger included

Pure® 13 BT primax Gain LengthL S / 45 n M / 60 n P / 70 n 0 1 2 3 4 *

R S / 45 n M / 60 n P / 70 n 0 1 2 3 4 *