Sonova Australia Pty td 12 Inglewood Place, orwest, SW 2153 Phone: 18 89 321 mail: ordersphonakcomau ective ovember 219 Phonak Audéo M RIC Order Form
Phonak Audéo M RIC Order Form For mild to severe hearing losses Rechargeable and zinc air RIC models capable of connecting to a broad range of devices via universal Bluetooth® and Phonak's Airstream technology. Step 1: Order details Account Number: 20 Hearing Clinic: Delivery Address: Contact Name: Email Address: Date Ordered: Phone Number: Date Required: Step 2: Patient information Name: Audiogram: (Required for AOV vent option) kHz 0.25 0.5 1 2 4 LEFT AC (dB HL) RIGHT AC (dB HL) Step 3: Warranty/VIP service 4th year ($140 ex GST) VIP 24 hour service ($50 ex GST) (VIP not available for Titanium products) Step 4: Choose hearing instrument (see following page for mould order, HSP codes and colour options) L R Model Part No. Colour M90-312 050-0494 L R Model Part No. Colour M90-312T 050-0498 L R Model Part No. Colour M90-13T 050-0519 M70-312 050-0493 M50-312 050-0492 M70-312T 050-0497 M50-312T 050-0496 M70-13T 050-0518 M50-13T 050-0517 M30-312 050-0491 M30-312T 050-0495 M30-13T 050-0516 L R Model Part No. Colour M90-R 050-0486 M70-R 050-0485 M50-R 050-0440 M30-R 050-0439 L R Model Part No. Colour M90-RT 050-0490 M70-RT 050-0489 M50-RT 050-0488 M30-RT 050-0487 Step 5: Choose receiver option (Sound Delivery System version 4.0 only) Standard S 0-L S 0-R Medium M 0-L M 0-R Power P 0-L P 0-R UltraPower cShell only HF3 filter recommended UP 0-L UP 0-R S 1-L S 1-R M 1-L M 1-R P 1-L P 1-R UP 1-L UP 1-R S 2-L S 2-R M 2-L M 2-R P 2-L P 2-R UP 2-L UP 2-R S 3-L S 3-R M 3-L M 3-R P 3-L P 3-R UP 3-L UP 3-R Step 6 (a): Choose dome coupling option (custom ear piece option below) Dome style Cap Left Right Dome Size Open Left Right Small Medium Large Vented Left Right Small Medium Large Power Left Right Small Medium Large Cap Open Vented Power Step 6 (b): Choose custom ear piece option (impression required) SlimTip (removable earpiece) L R Material Hard Acrylic Hard Acrylic cShell Acrylic cShell Titanium* L R Shell colour Beige/Pink Beige/Pink Soft Silicone Soft Silicone Clear Clear Titanium* Clear Titanium* Shell colour Clear Tan Tan Faceplate colour Pink Pink Rosa Tint Beige/Pink (hard only) Tan (hard only) Rosa Tint Beige/Pink (hard only) Tan (hard only) *Please note SlimTip and cShell Titanium products are not included free of charge with hearing aid order. Cocoa Brown Transparent Tan Black Transparent Cocoa Brown Transparent Tan Black Transparent Impressions New impressions enclosed Use scanned data Existing serial number: SlimTip Titanium SlimTip cShell Titanium cShell Okay to change to cShell if SlimTip not possible Sonova Australia Pty Ltd | 12 Inglewood Place, Norwest, NSW 2153 | Phone: 1800 809 321 | Email: orders@phonak.com.au Effective November 2019 Phonak Audéo M RIC Order Form For mild to severe hearing losses Rechargeable and zinc air RIC models capable of connecting to a broad range of devices via universal Bluetooth® and Phonak's Airstream technology. Step 7: Choose venting, wax management and handling options Venting (mm)* LR AOV Let Phonak decide. Please fill out audiogram thresholds on previous page. Occluded 1.0 mm 1.1 - 1.6 mm 1.7 - 2.2 mm 2.3 - 3.0mm Open *Cerustop default option for SlimTip HA and only option for SlimTip Titanium. Wax management L R SlimTip Hard Acrylic Cerustop Ext. receiver tube + wax spring None L R SlimTip Soft Silicone None L R SlimTip Titanium Cerustop L R cShell Cerustop HF3 (recommended for UP Rx) HF4 Ext. receiver tube + wax spring** *Not applicable for cShell Titanium. Handling LR Removal Line Removal Line + 5mm extension Canal Lock Skeleton Lock Step 8: CROS Fitting? There are no compatible CROS Transmitters available for the Marvel platform - please consider Belong platform CROS solutions. Special requests: Step 9: Choose accessories Cleaning kits Choose one complimentary option C&C Cleaning Kit (098-0041) D-Dry Electronic Kit (098-0083-00014)* *Not recommended for Audeo M-R/RT Complimentary charging accessory (for Audéo M-R/RT) Phonak Charging Case Combi (075-0040) Phonak Mini Charger Case coming soon Additional charging accessory (for Audéo M-R/RT) Phonak Power Pack (071-0003) Additional information HSP codes Other accessories TV Connector (076-3006-06) Remote Control (076-0065-P5) PartnerMic (076-4001-P510) Roger Accessories - please complete the Phonak Roger Order Form Model Code Category M90-312 B599PHO C2 M70-312 B601PHO C2 M50-312 B603PHO C2 M30-312 B605PHO C2 Model Code Category M90-312T B611PHO C2 M70-312T B612PHO C2 M50-312T B613PHO C2 M30-312T B614PHO C2 Model Code Category M90-13T B615PHO C2 M70-13T B616PHO C2 M50-13T B617PHO C2 M30-13T B618PHO C2 Model Code Category M90-R B600PHO C2 M70-R B602PHO C2 M50-R B604PHO C2 M30-R B606PHO C2 Model Code Category M90-RT B607PHO C2 M70-RT B608PHO C2 M50-RT B609PHO C2 M30-RT B610PHO C2 Housing colours Models P1 Sand Beige P7 Graphite Gray P3 Sandalwood P8 Velvet Black P4 Chestnut T7 Alpine White P5 Champagne H0 Beige P6 Silver Gray Audéo M-R/RT charging accessories Other accessories Audéo M-312 Audéo M-312T Audéo M-13T Audéo M-R Audéo M-RT Phonak Charger Case Combi Phonak Power Pack 075-0040 071-0003 TV Connector 076-3006-06 RemoteControl 076-0065-P5 PartnerMicTM 076-4001-P510 Sonova Australia Pty Ltd | 12 Inglewood Place, Norwest, NSW 2153 | Phone: 1800 809 321 | Email: orders@phonak.com.au Effective November 2019Adobe PDF Library 15.0 Adobe InDesign 14.0 (Macintosh)