L R MK604951 Rev D 2019.03 5 RESOUND WIRELESS ACCESSORIES ($) ReSound Remote Control 2 ($) ReSound TV Streamer 2 ($) ReSound Phone Clip ($) ReSound Multi Mic ($) ReSound Micro Mic
Patient’s name: SSN: LAST: FIRST: Previous user: YES NO Audiogram data: 250 500 750 1k 1.5k 2k 3k 4k 6k 8k Left air: Bone: LDL: Right air: Bone: LDL.. View
GOVERNMENT SERVICES ORDER FORM
RESOUND LINX QUATTRO AND LINX 3D RIC
1.800.392.9932 FAX 1.888.768.1867
RACHAP ACTIVE DUTY INDIAN HEALTH
TRICARE CHOICE
BILL TO Acc't #:
· Office: Address: Address: City/State: Zip:
SHIP TO Acc't #:
Date: Contact name: Email: · Facility: Address: Address: City/State: Zip:
P.O. Phone:
1 PATIENT DATA
Patient's name:
SSN:
LAST:
FIRST:
Previous user:
YES
NO
Audiogram data:
250 500 750 1k 1.5k 2k 3k 4k 6k 8k
Left air:
Bone:
LDL:
Right air:
Bone:
LDL:
2 SPECIAL INSTRUCTIONS
(PLEASE PRINT CLEARLY)
3 MODEL AND OPTIONS
2.4GHz wireless
ReSound LiNX Quattro
Portable charging case included in order of RE961)
Mini RIC
L
R
RE961
Mini RIC
L
R
Mini RIC
L
R
RIC
L
R
RE962
2.4GHz wireless
ReSound LiNX 3D
LT961
LT961-Z
LT962
Battery
Lithium-ion rechargeable
#312
#312
#13
Program selector Programmable Programmable Programmable Multifunction
Push button Push button Push button
Switch
Volume control Programmable Programmable Programmable Multifunction
Push button Push button Push button
Switch
RIC receivers (power level)
Low power (LP)
Medium power (MP)
High power (HP)
Ultra power (UP)*
Color (keychain color) Dark brown (4) Beige (5) Light blonde (6) Medium blonde (7)
Monza red (8)
Black (9)
Anthracite (10) Silver (11) Forest camo Desert camo Ocean camo Pearl white (12) Ocean blue (13) Sterling gray (14)
Gloss black (15)
Gloss anthracite (16)
Gloss medium blonde (17)
White
* UP receiver only available in Encased earmolds
(#) Color keychain reference
AVAILABLE
DEFAULT
4a RESOUND RIC RECEIVERS AND DOMES
RIC Receiver tube length Size L R
0
1
2
3
4
Size
Large Medium
Small Tulip
DOMES L R
Large Medium
Small
POWER
STD
OR 4b
CUSTOM RIC EARMOLD OPTIONS
For proper fit, measure from the top of the ear to the center of the ear canal using the ReSound measuring tool.
DEFAULT
AVAILABLE
5 RESOUND WIRELESS ACCESSORIES
($) ReSound Remote Control 2 ($) ReSound TV Streamer 2 ($) ReSound Phone Clip+ ($) ReSound Multi Mic ($) ReSound Micro Mic ($) ReSound LiNX Quattro RE961
Portable Charging Case (additional)
($) Additional charge for wireless accessories
MATERIAL Hard (acrylic)
Soft (silicone) (n/a for Encased and Hollow Cavity)
ENCASED MICROMOLD HOLLOW CAVITY
LR LR LR
SKELETON
LR
INSTRUMENT INFORMATION MODEL
TRUFITTM IMPRESSION--THE 16/4 RULE
Take an OPEN JAW impression when: · Ear geometry lacks retention · Patient has severe TMJ movement 16mm · Instrument migrates out of ear · Instrument is loose or has feedback
4mm
Full helix
RECEIVER
Include (check): YES NO Size:
Low power (LP). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L R
Medium power (MP). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L R
High power (HP). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L R
Ultra power (UP) (Encased only) . . . . . . . . . . . . . . . . . . . . . . . . L R
SHELL COLOR Clear. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L R Light. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L R Medium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L R Dark. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L R Rose (n/a for Encased nor Hollow Cavity). . . . . . . . . . . . . . . L R EarLusion Light (n/a for Encased nor Hollow Cavity) . . . . L R Espresso (hard only). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L R Red/Blue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L R
FACEPLATE COLOR (Encased only) Light. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L R
Beige . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L R Medium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L R Dark. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L R Espresso . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L R Anthracite . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L R Clear. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L R
CANAL LENGTH Factory select . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L R As marked. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L R
VENTING Factory select . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L R MOV (Semi-IROS vent modification recommended) . . . . . . . . . L R SAV. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L R Pressure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L R None. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L R
VENT MODIFICATION Semi-IROS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L R IROS (n/a for Hollow Cavity). . . . . . . . . . . . . . . . . . . . . . . . . . L R
WAX PROTECTION (Encased and hard only, n/a for Hollow Cavity) HF3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L R CeruSTOP (default for Encased). . . . . . . . . . . . . . . . . . . . . . . . L R None (default for hard, STD for Hollow Cavity). . . . . . . . . . . . . L R
OTHER OPTIONS Removal cord. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L R Blue/Red dots . . . . . . . . . . . . . . . . . . . . . . . Size (check): SMALL or LARGE
Patient initials. . . . . . . . . . . . . . . . . . . . . . . .
RETENTION Canal Lock (n/a for Skeleton). . . . . . . . . . . . . . . . . . . . . . . . . . L R Helix Lock (n/a for Hollow Cavity and Skeleton). . . . . . . . . . L R Skeleton Lock (n/a for Skeleton) . . . . . . . . . . . . . . . . . . . . . . . L R Semi-Skeleton Lock (n/a on Hollow Cavity and Skeleton) L R
PLEASE SEND
Air bills
Impression mailers
MK604951
MK604951 Rev D 2019.03
Adobe PDF Library 15.0