WIRELESS CUSTOM ORDER FORM
HIGHLIGHTED / GRAY AREAS MUST BE COMPLETED FOR APPROPRIATE MATRIX SELECTION
STEP 1 - ORDER
ORDER
BILL TO:
SHIP TO:
AHB ACCOUNT NUMBER:
ADDRESS:
AHB ACCOUNT NUMBER:
ADDRESS:
CONTACT:
PHONE:
CONTACT:
PHONE:
EMAIL:
FAX:
EMAIL:
FAX:
CELL PHONE:
CELL PHONE:
SERVICE OPTIONS (ADDITIONAL CHARGES APPLY)
WARRANTY OPTIONS (REPAIR/LOSS & DAMAGE)
SAME-DAY SERVICE
ONE-DAY SERVICE
2ND YEAR
3RD YEAR
4TH YEAR
5TH YEAR
STEP 2 - PATIENT (FILL OUT PATIENT’S NAME, DOB/AGE AND DATE)
REFERRING ORGANIZATION
FIRST NAME
TEST DATA
LAST NAME
MCL L:
MCL R:
PATIENT DOB/AGE
UCL L:
DATE
HEARING AID HISTORY
UCL R:
Air
RIGHT
Bone
LEFT
PREVIOUS USER
YES
NO
PREVIOUS VENT SIZE
RIGHT
PREVIOUS USER
YES
NO
L:
Frequency
2505007501K2K 3K4K 6K8K
OUTPUT/MAKE
Air
LEFT
Bone
GAIN/MODEL
R:
SERIAL NO.
(IF STARKEY HEARING TECHNOLOGIES)
STEP 3 - PRODUCT (BOLD INDICATES THE DEFAULT)
HEARING AID ORDER REQUIREMENTS
FACEPLATE/SHELL OPTIONS (CHOOSE ONE)
FILL IN SELECTION BELOW
STYLE OPTIONS
IN-THE-EAR
HALF SHELL*
IN-THE-CANAL
COMPLETELY-IN-CANAL
FACEPLATE/SHELL COLOR
USER CONTROLS (CHOOSE ONE)
NO USER CONTROL
DIGITAL ROTARY VC**
PUSH BUTTON (VC OR MEMORY)
DIGITAL ROTARTY VC +
MEMORY BUTTON**
CHARGEABLE OPTIONS
DIRECTIONAL**
VOC OPTIONS
STACKED VC (DVC ONLY)
INDUCTION COIL**
VENTING OPTIONS
FACTORY SELECT
NO VENT
1 VENT
2 VENT
MINI VENT
VARIABLE VENT
BLUE/RED
PINK/CLEAR
CLEAR
LIGHT BROWN/LIGHT BROWN
DARK BROWN/CLEAR
AUDIBEL
WAX PREVENTION
MED BROWN/RED/BLUE (CIC)
HEAR CLEAR
MED BROWN/CLEAR (CIC)
EXTENDED RECEIVER TUBE
CHESTNUT BROWN/CLEAR
IROS VENT
IROS OPEN VENT
REMOVAL & FINISH OPTIONS
REMOVAL NOTCH
(NOT AVAILABLE IN CIC)
STARKEY
OPTIONAL SHELL COLOR
PINK/PINK (ITE-ITC)
NUEAR
REMOVAL HANDLE
DULL/MATTE FINISH
SDS Wireless Premier
3 Series i110
A2 Wireless Platinum
3 Series i90
A2 Wireless Gold
SDS Wireless Pro
3 Series i70
A2 Wireless Silver
SDS Wireless Prestige
3 Series i30
Start Wireless 8
Intro Wireless 5
3 Series i20
Start Wireless 7
Intro Wireless 4
Wi Series i110
Range Wireless Platinum
LOOK Wireless Premier
Wi Series i90
Range Wireless Gold
LOOK Wireless Pro
Wi Series i70
Range Wireless Silver
LOOK Wireless Prestige
Ignite i30
Start Wireless 6
Intro Wireless 3
Ignite i20
Start Wireless 5
Intro Wireless 2
*NOT AN AVAILABLE STYLE FOR AUDIBEL
**NOT AVAILABLE IN CIC
SPECIAL INSTRUCTIONS:
© 2014 Starkey Hearing Technologies. All Rights Reserved. 6/14 FORM0211-03-EE-HB
DO NOT WRITE HERE
FACTORY USE ONLY
WIRED CUSTOM ORDER FORM
HIGHLIGHTED / GRAY AREAS MUST BE COMPLETED FOR APPROPRIATE MATRIX SELECTION
STEP 1 - ORDER
ORDER
BILL TO:
SHIP TO:
AHB ACCOUNT NUMBER:
ADDRESS:
AHB ACCOUNT NUMBER:
ADDRESS:
CONTACT:
PHONE:
CONTACT:
PHONE:
EMAIL:
FAX:
EMAIL:
FAX:
CELL PHONE:
CELL PHONE:
SERVICE OPTIONS (ADDITIONAL CHARGES APPLY)
WARRANTY OPTIONS (REPAIR/LOSS & DAMAGE)
SAME-DAY SERVICE
ONE-DAY SERVICE
2ND YEAR
3RD YEAR
4TH YEAR
5TH YEAR
STEP 2 - PATIENT (FILL OUT PATIENT’S NAME, DOB/AGE AND DATE)
REFERRING ORGANIZATION
FIRST NAME
TEST DATA
LAST NAME
MCL L:
MCL R:
PATIENT DOB/AGE
UCL L:
DATE
HEARING AID HISTORY
UCL R:
Air
RIGHT
Bone
LEFT
PREVIOUS USER
YES
NO
PREVIOUS VENT SIZE
RIGHT
PREVIOUS USER
YES
NO
L:
Frequency
2505007501K2K 3K4K 6K8K
OUTPUT/MAKE
Air
LEFT
Bone
STEP 3 - PRODUCT (BOLD INDICATES THE DEFAULT)
FACEPLATE/SHELL COLOR
FILL IN SELECTION BELOW
VENTING OPTIONS
BLUE/RED
PINK/CLEAR
CLEAR
LIGHT BROWN/LIGHT BROWN
FACTORY SELECT
DARK BROWN/CLEAR
HALF SHELL*
NO VENT
MED BROWN/RED/BLUE (CIC)
IN-THE-CANAL
1 VENT
MEDIUM BROWN/CLEAR
COMPLETELY-IN-CANAL
2 VENT
CHESTNUT BROWN/CLEAR
STARKEY
AUDIBEL
HEAR CLEAR
EXTENDED RECEIVER TUBE
REMOVAL & FINISH OPTIONS
REMOVAL NOTCH
VARIABLE VENT
DULL/MATTE FINISH
(NOT AVAILABLE IN CIC)
REMOVAL HANDLE
IROS OPEN VENT
INDUCTION COIL**
WAX PREVENTION
MINI VENT
IROS VENT
DIRECTIONAL**
OPTIONAL SHELL COLOR
PINK/PINK (ITE-ITC)
IN-THE-EAR
CHARGEABLE OPTIONS
SERIAL NO.
(IF STARKEY HEARING TECHNOLOGIES)
FACEPLATE/SHELL OPTIONS (CHOOSE ONE)
HEARING AID ORDER REQUIREMENTS
STYLE OPTIONS
GAIN/MODEL
NUEAR
3 Series 110
A2 Platinum
SDS Premier
3 Series 90
A2 Gold
SDS Pro
3 Series 70
A2 Silver
SDS Prestige
3 Series 30
Start 8
Intro 5
3 Series 20
Start 7
Intro 4
Ignite 30
Start 6
Intro 3
Ignite 20
Start 5
Intro 2
SPECIAL INSTRUCTIONS:
USER CONTROLS (CHOOSE ONE)
NO USER CONTROL
DIGITAL ROTARY VC**
DIGITAL ROTARY VC + MEMORY BUTTON**
ANALOG VC
ANALOG ROTARY VC +
MEMORY BUTTON**
PUSH BUTTON (VC OR MEMORY)
VIC OPTIONS
STACKED VC (DVC OR AVC ONLY)
R:
*NOT AN AVAILABLE STYLE FOR AUDIBEL
**NOT AVAILABLE IN CIC
© 2014 Starkey Hearing Technologies. All Rights Reserved. 6/14 FORM0211-03-EE-HB
DO NOT WRITE HERE
FACTORY USE ONLY