SNAPFIT POWER RECEIVER CUSTOM FIT (EMBEDDED) RIC ORDER FORM
HIGHLIGHTED / RED 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)
SAME-DAY SERVICE
ONE-DAY SERVICE
STEP 2 - PATIENT
REFERRING ORGANIZATION
PATIENT NAME
TEST DATA
PATIENT DOB/AGE
MCL L:
MCL R:
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
SERIAL NO.
(IF STARKEY HEARING TECHNOLOGIES)
STEP 3 - PRODUCT (BOLD INDICATES THE DEFAULT)
HEARING AID ORDER REQUIREMENTS
POWER RECEIVER REQUIREMENTS
FILL IN SELECTION BELOW (CIRCLE THE MODEL YOU WOULD LIKE TO ORDER)
STYLE OPTIONS
RIC 312
MICRO RIC 312
PRODUCT NAME
RIC 13 MODELS**
RIC 312 MODELS
RIC 312 & MICRO RIC 312 MODELS
MICRO RIC 312 MODELS
STARKEY
HALO i110
HALO i90
HALO i70
STARKEY
3 SERIES i110
3 SERIES 110
3 SERIES i90
3 SERIES 90
3 SERIES i70
3 SERIES 70
3 SERIES i30
3 SERIES 30
3 SERIES i20
3 SERIES 20
AUDIBEL
A2 WIRELESS PLATINUM
A2 WIRELESS GOLD
A2 WIRELESS SILVER
A2 PLATINUM
A2 GOLD
A2 SILVER
START WIRELESS 8
START WIRELESS 7
START 8
START 7
STARKEY
XINO WIRELESS i110
XINO WIRELESS i90
XINO WIRELESS i70
XINO WIRELESS i30
XINO WIRELESS i20
XINO CLASSIC 110
XINO CLASSIC 90
XINO CLASSIC 70
XINO CLASSIC 30
XINO CLASSIC 20
NUEAR
SDS WIRELESS PREMIER
SDS WIRELESS PRO
SDS WIRELESS PRESTIGE
SDS PREMIER
SDS PRO
SDS PRESTIGE
INTRO WIRELESS 5
INTRO WIRELESS 4
INTRO 5
INTRO 4
AUDIBEL
A2 CLASSIC PLATINUM
A2 CLASSIC GOLD
A2 CLASSIC SILVER
START CLASSIC 8
START CLASSIC 7
NUEAR
iSDS PREMIER
iSDS PRO
iSDS PRESTIGE
RIGHT
THIS POWER RECEIVER ATTACHES TO:
RIC 13
AUDIBEL
A3i PLATINUM
A3i GOLD
A3i SILVER
LEFT
HEARING AID COLOR OPTIONS
CHOOSE PRODUCT COLOR TO MATCH HAIR COLOR
STANDARD COLOR OPTIONS
BLACK
STERLING
PURPLE POP
FUCHSIA
FABULOUS
BLUE ICE
SLATE
BRONZE
PINK PIXIE
BLUE PACIFIC
BLACK W/ STERLING*
LEFT
NO VENT
1MM
2MM
3MM
BAV
RIGHT
NO VENT
1MM
2MM
3MM
BAV
SHELL OPTIONS
CANAL
CANAL LOCK
HEAR CLEAR
CLEAR SHELL
HALF SHELL
FOAM FILTER
RED/BLUE TIPPED SHELL
FULL SHELL
BICONIC WAX GUARD
RECEIVER CABLE LENGTH REQUIRED
LEFT
1
2
3
4
5
RIGHT
1
2
3
4
6
BRIGHT COLOR OPTIONS
RED HOT
BRIGHT WHITE W/ STERLING*
VENTING OPTIONS
NUEAR
SDS CLASSIC PREMIER
SDS CLASSIC PRO
SDS CLASSIC PRESTIGE
INTRO CLASSIC 5
INTRO CLASSIC 4
ESPRESSO
CHAMPAGNE
*AVAILABLE AS SPECIAL EDITION COLORS FOR RIC 13 ONLY.
**NOT AVAILABLE IN BRIGHT COLOR OPTIONS.
© 2014 Starkey Hearing Technologies. All Rights Reserved. 4/14 FORM2605-03-EE-HB
R:
DO NOT WRITE HERE
FACTORY USE ONLY
ORIGINAL POWER CUSTOM FIT (EMBEDDED) RIC ORDER FORM
HIGHLIGHTED / RED 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)
SAME-DAY SERVICE
ONE-DAY SERVICE
STEP 2 - PATIENT
REFERRING ORGANIZATION
PATIENT NAME
TEST DATA
PATIENT DOB/AGE
MCL L:
MCL R:
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
Air
LEFT
Bone
OUTPUT/MAKE
GAIN/MODEL
SERIAL NO.
(IF STARKEY HEARING TECHNOLOGIES)
STEP 3 - PRODUCT (BOLD INDICATES THE DEFAULT)
HEARING AID ORDER REQUIREMENTS
ABSOLUTE POWER RECEIVER REQUIREMENTS
FILL IN SELECTION BELOW
LEFT
STARKEY
AUDIBEL
NUEAR
XINO TINNITUS 90*
A2 TINNITUS GOLD*
SDS TINNITUS PRO*
XINO TINNITUS 30*
START TINNITUS 8*
INTRO TINNITUS 5*
RIGHT
THIS POWER RECEIVER ATTACHES TO:
3 SERIES
XINO WIRELESS
TOUR
VENTING OPTIONS
XINO 110
ANTHEM XT PLATINUM
IMAGINE 2 PREMIER
XINO 90
ANTHEM XT GOLD
IMAGINE 2 PRO
LEFT
NO VENT
1MM
2MM
3MM
BAV
XINO 70
ANTHEM XT SILVER
IMAGINE 2 PRESTIGE
RIGHT
NO VENT
1MM
2MM
3MM
BAV
XINO 30
START 6
INTRO 3
XINO 20
START 5
INTRO 2
*NOT AVAILABLE IN BRIGHT COLOR OPTIONS
HEARING AID COLOR OPTIONS
CHOOSE PRODUCT COLOR TO MATCH HAIR COLOR
STANDARD COLOR OPTIONS
BRIGHT COLOR OPTIONS
CHAMPAGNE
PEARL
RED HOT
ONYX
STERLING
PURPLE POP
FUCHSIA
FABULOUS
BLUE ICE
SLATE
BRONZE
PINK PIXIE
BLUE PACIFIC
SHELL OPTIONS
CANAL
CANAL LOCK
HEAR CLEAR
CLEAR SHELL
HALF SHELL
FOAM FILTER
RED/BLUE TIPPED SHELL
FULL SHELL
BICONIC WAX GUARD
RECEIVER CABLE LENGTH REQUIRED
LEFT
1
2
3
4
5
RIGHT
1
2
3
4
5
SPECIAL INSTRUCTIONS:
DO NOT WRITE HERE
FACTORY USE ONLY
© 2014 Starkey Hearing Technologies. All Rights Reserved. 4/14 FORM2605-03-EE-HB
R: