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Custom Earmold/Swim Plug Order Form - Unitron
L R Custom Earmold/Swim Plug Order Form Canal mold Canal mold Canal lock Helix lock Semi skeleton Skeleton Carved half shell Carved full shell Full shell Canal lock Helix lock Semi skeleton
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Custom Earmold/Swim Plug Order Form = indicates standard option $ = indicates chargeable option Step 1 Ship to: Clinic details 48 HOUR RUSH $ Clinician name: ____________________________ Approval required if substitutions are necessary? Telephone: _______________________________ Yes No E-mail: _________________________________ Claim type: FHP (VAC, NIHB, ETC) WCB _____ Province PO#: ___________________________________ Claim number: ___________________________ Step 2 Patient details AUDIOMETRIC INFORMATION 250 500 1000 2000 3000 L 4000 R Patient's first name: ________________________________ Patient's last name: ________________________________ Order date: ________________________________________ Fitting date: _______________________________________ Step 3 Canal mold Skeleton Step 5 Earmold Style Canal lock Helix lock Carved half shell Carved full shell LR Semi skeleton Canal mold Canal lock Helix lock Semi skeleton Full shell Skeleton Carved half shell Carved full shell Full shell Earmold/Swim Plug Materials Colour Lacquer Swim plug materials LR Floatable silicone Step 4 Canal Length and Venting Details Canal length LR Short Medium Long Ear texture Soft Average Firm short long medium Venting Intellivent* No vent/occluded Other: L mm R mm *Audiogram required Step 6 Tube/Connector Details Note: Soft earmolds come standard with prelocked tubing (TRS) ID: Inner diameter OD: Outer diameter Colour Earmold materials Acrylic hard (lucite) Silicone soft 70 Silicone very soft 40 N/A N/A N/A N/A Colour LR Blue (07) Red (10) Green (17) Yellow (20) Pink (26) Light Blue (34) N/A N/A Step 7 Select a product and platform (optional step) Stride P LR LR LR LR LR Tempus North Pro 800 700 600 500 Stride P Dura Pro 800 700 600 500 Stride M Pro 800 700 600 500 Stride M R Pro 800 700 600 500 N/A Max SP Max UP Pro 800 700 600 500 N/A Pro 800 700 600 500 N/A Tube/Connector details 13 medium tube (ID 1.9, OD 3.2) 13M 13 thick wall tube (ID 1.9, OD 3.3) 13T 13 dry wall tube (ID 1,9, OD 3.2) 13D 13 dry thick wall tube (ID 1.9, OD 3.3) 13W Power SlimTube - Max only (ID 1.4, OD 2.0) PST N/A with soft ** Transparent tube only Special notes 00/0/1/2/3 N/A N/A N/A N/A L R ** ** N/A N/A N/A Clear/ Transparent (21) Rose tint (T) Transparent brown (N) Glossy finish Matte finish SlimTube length Clear / Transparent (21) Rose tint (M4) Transparent brown (L7) Connector QuickSnap (TLG) 027-5781-02 Printed in Canada WP-09/2018 45 Washburn Drive, Unit A, Kitchener ON N2R 1S1 | Telephone: 1-800-265-8255 | Fax: 1-800-949-6663