Unitron Earmold Order Form (US)

All-make earmold order form

Canal length L

Step 1 Ship to Ship to account number _ ______________________________________ Acccount name_________________________________________________ Address_ _____________________________________________________ City_ ______________________State_______Zip code_ ________________ Third party bill to _ ____________________________________________ Purchase order number__________________________________________ Medicaid number_______________________________________________ Contact information Date_ ________________________________________________________ Contact name__________________________________________________ Phone________________________________________________________ Email address__________________________________________________ Rush 24 Hour Rush (additional charge) 48 Hour Rush (additional charge) Step 2 Patient information First______________________________________________ Last__________________________________________________________ Patient audiogram 250 Hz 500 Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz Left Right Step 3 Items included with order Receivers(s) or slim tube(s) MUST be sent with your order Other manufacturer items included with ear impression (GO) L R Receiver Manufacturer name: _ _________________________________ L R Slim tube Manufacturer name: _ ________________________________ Please do NOT send hearing instruments Step 4 Earmold options Shell style L R Skeleton (SK) L R Semi skeleton (SS) L R Full shell (SC) L R Full shell uncarved (SU) L R Half shell (HC) L R Canal lock (CL) L R Canal (CU) L R CROS (CB) L R Solid sleeve (SO) Adult Pediatric (10 & under)

R Full length of impression (X)

L L L

R Long (RL)

L L

R Cut to mark

R Medium (RM)

R Extra long (RG)

R Short (RS)

Finish

Gloss (HC) (standard)

Satin (SA)

Tubing options L

R 13 Regular (13s) (std foracrylicearmolds) R 13 Heavy wall (13T) (std forsiliconeearmolds)

L L

R QuickSnap regular (TLG) R QuickSnap heavy wall (TLG)

L

*TRS tubing retention system default with silicone earmolds

Venting Select-a-vent (S) L

R Pressure vent 1.5mm (S15) R Small 1.8 mm (S18) R Medium 2.5 mm (S25) R Large 3.0 mm (S30)

L L L

L L

R R

IROS vent (S, IA)

No vent (X) If vent selection left blank, default vent selection will be used Shell options L R Removal filament (RF) L R Canal lock (CL) L R Bell canal (BC) Step 5 Special instructions

Earmold material L R Acrylic (AC) L

Earmold color Acrylic & silicone colors Clear (21) (standard) Translucent pink (T) Translucent brown (N)

Specialty color _____ Colorcodesbelow.Siliconeonly. Swirl. Pick up to 3: _____ _____ _____

R Silicone (S70) R Soft silicone (S40)

L

Colorcodesbelow. Solidsiliconeonly.

Silicone glitter: Sugar plum (L1) Bubble gum (K5) Cotton candy (K6) Cherry popsicle (K7)

Raspberry fizz (V8) Wintermint (L4) Tealicious (W1) Blueberry slush (K4) Royal blast (V9)

Lemon drop (K8) Sugar cube (L3) Shimmering moonbeam (W2)

Silicone solid: Red (10) Purple (08) Blue (07) Yellow (20)

Orange (11) Green (17) Black (06) White (19)

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