Unitron BTE and Earmold Order Form (US)

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___________________________________________Age_ ___________ Last__________________________________________________________ Patient audiogram 250 Hz 500 Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz Left Right Unitron BTE and Earmold Order Form Stride family

Step 5 Custom options Shell style L R Skeleton (SK) L R Semiskeleton(SS) L R Full shell (SC) L L L

R Half shell (HC) R Canal lock (CL)

L L L

R CROS (CB)

R Hollowsleeve(HO) R Solidsleeve(SO)

R Canal (CU)

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) Candy apple (K3) Canal length L

Cherry popsicle (K7) Limeade (K9) Wintermint (L4) Sour apple (L2) Blueberry slush (K4)

Orange sorbet (K0) Lemon drop (K8) Sugar cube (L3)

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

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

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 Slim tube length

0 L

R 1 L

R 2 L

R 3 L

R

L

R 13 Regular (std foracrylicearmolds) n/awithsilicone(13s)

L L

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

L L

R 13 Heavy wall (13T)

R 13 Heavy wall w/TRS (13T) (standardwithsilicone) *

Step 3 Hearing instrument selection Please add to order Already have the following Pro 800 700 600

*TRS tubing retention system default with silicone earmolds Venting L

500

Stride M Stride P

R Intellivent (audiogram required) (AO)

L

R

L

R

L

R

L

R

L

R

Cavity vent (Y) * L

Select-a-vent (S) L

L

R

L

R

L

R

L

R

L

R

R Pressure vent 1.5 mm (Y15) R Small 1.8 mm (Y18) R Medium 2.5 mm (Y25) R Large 3.0 mm (Y30)

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

Stride P Dura

L

R

L

R

L

R

L

R

L

R

L L L

L L L

Color

Beige (01) Amber (P2)

Pewter (P7) Charcoal (P8) Cinnamon (Q9) Amber suede (S2)

Espresso boost (S3) Pewter shine (S5) Sand storm (S6) Teal blast (S7)

L L L

R R R

IROS vent (S, IA)

Espresso (P4) Platinum (P6)

As large as possible

No vent (X) *Cavity vent default on hollow sleeve mold Shell options L R Removal filament (RF) L R Canal lock (CL) (N/A with soft sleeve)

01 Beige

P2 Amber

P4 Espresso

P6 Platinum

P7 Pewter

P8 Charcoal

L

R

Bell canal (BC)

Q9 Cinnamon

S2 Amber suede

S3 Espressoboost

S5 Pewter shine

S6 Sand storm

S7 Teal blast

Step 6 Special instructions

Warranty Service

1 yr 2 yr 3 yr 4 yr

L&D

1 yr 2 yr 3 yr 4 yr Step 4 Wireless accessories Remote control 2 uTV ™ 3 uStream uDirect ™ 3

uMic ™

Please send:

Shipping labels Order forms Impression boxes Repair forms

800.888.8882 | FAX 800.521.5400 | 14755 27 th Ave. N. | Plymouth, MN 55447 | unitron.com/us

027-5813-03 04-16 3064 © 2016 Unitron

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