Custom Products Order Form

Custom Products Order Form
Ship To Information
Fitter's Information
Today’s Date:________________
Your Information
Customer Number:
Fitter’s Name:__________________________________________
(Please complete all information including name & phone number)
Phone #:(
)_______________
Purchase Order #:___________ Fitter’s E-mail:__________________________________________
Company Name:________________________________________
Patient Information
Address: ______________________________________________
First Name:
Age:
Middle
Initial:
City:_______________________ State:_______ Zip:________
Last Name:
Bill To Information
Last 4 Digits of Social Security #:
Bill To Number:
Alta2 Pro
Power Ultra Power Omni
(90)
(100)
Only
Battery
L R
Alta2 Pro
Fitting Date: _______________
Auto Phone
PB*
†
L R
L R
L R
L R
NA
NA
STD
NA
STD
IIC**
10A
CIC
10A
NA
Canal
312
NA
Half Shell
312
13
NA
Full Shell
312
13
NA
VC
Remote
T-coil Auto-T Control
(not available
with Tcoil)
Streamer
Pro 1.3A
L R
L R
L R
Black
Black White
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
All models
default to
Directional
Microphones
unless Omni is
selected.
*Push button
needed for
T-coil access.
Push button is
default on custom
instruments
unless otherwise
indicated.
**non-wireless
ConnectLine™ Options
†
‡ Custom instruments offer only 1 control per instrument.
 TV Adaptor
 Phone Adaptor
 ConnectLine Mic
Select one option for each instrument if desired.
Volume control or Push button
Left
Right
Audiometric Information:
Color Options
More Options
IIC Faceplate
IIC Shell
Black (default)
Pink
Tan
Med. Brown
Dark Brown
Red/Blue (default)
Pink
Clear
Alta Pro
Pink (default)
Pink (clear shell)
Tan
Tan (clear shell)
Medium Brown (clear shell)
Dark Brown (clear shell)
Hz
Long
500
1K
3K
4K
8K
Impression Information:
Type : Open jaw  Closed jaw  Return Impressions 
Other Options
As marked on impressions
Small Vent
Large Vent
SAV Vent
Medium Vent
Max Vent
Pressure Vent
No Vent
Raised VC
Canal Lock
Removal String
(Standard on IIC/CIC)
Raised PB
Clothing Loop
Removal notches
Include Spanish
Instructions
Special Instructions
15500-2091/ 4.15
2K
AC Left
Venting: Factory Selected (largest possible)
Style:
Vent Diameter:
250
AC Right
Canal Length: (Factory STD unless otherwise marked)
Medium
 VC OR  PB
 VC OR  PB
Phone 877-310-9681 • Fax 732-764-9133 • www.oticonusa.com
Reference Guide
Inium Custom
Products Order Form
Venting
All vents are calculated in Genie, unless other wise indicated on the order form. For a specific vent type please note it in special
instructions.
Collection Vent
Cone shape channel, round opening
faceplate, "D' opening on canal tip.
Most common for ITC, HS, and FS
where pressure vents not necessary.
Cast Vent
Straight channel through device.
Round opening on faceplace and
canal tip. Used when pressure
vents are indicated.
Oval Vent
Oval openings used for smaller
instruments IIC and CIC.
Free Vent
Free form openings, takes
advantage of space to ensure
largest vent possible.
Accessories
T-Cap
The nano-coated, waxrepellent T-Cap filter is
used for all miniature
custom styles.
O-Cap
The new nano-coated O-Cap
microphone protection filter is
designed to reject wax and fits
all instruments using battery
size 312 and 13.
ProWax
Providing advanced receiver
port protection, the ProWax
filter fits all styles in the
new Oticon custom
program.
T Cap (mic cover)
Gray compact/Black tools
O Cap (mic cover)
Gray compact/Black tools
ProWax
Gray “turtle”/Lt Gray tools
Part Number (1 pc):
123328 - Beige
123330 - Light Brown
123331 - Med Brown
123329 - Dark Brown
123327 - Black
Part Number (1 pc):
128003 - Beige
128004 - Light Brown
128005 - Med Brown
128006 - Dark Brown
Part Number (1 pc):
123367
Custom Option for Special Needs
Instrument
Removal Options
Large Ball
Reinforced
Removal Line
Door Hook
Tactile Options
Raised Push
Button
VW Large,
Small or
Raised
Battery Indicator
Clothing Loops
Loops:
Metal Small
and Large
Plastic:
Small and
Large
Plastic Combo:
Loop+removal
string
Helix Lock
Spiral Retention
Ring
Retention Options Canal lock
Please include your request on the comment line of the order form. Options available space permitting and may not be available on all models.
*Push button serves as program change; T-coil access and volume change.
†All models default to Directional Microphones unless Omni is selected.
‡Technical information re 2cc coupler:
Power Receiver: OSPL90 PK 121, PK Gain: 54, Ultra Power Receiver: OSPL90 PK 127,
Pk Gain: 62