Date Order :
*
Date Required :
*
PO/Indent No :
Hearing Clinic :
Client Name:
Client ID :
Age :
Ordered By:
*
Contact Phone :
Contact Email ID:
Step 1. Enter the Audiogram - Air Conduction only. (Required for AOV)
Ear
250Hz
500Hz
750Hz
1kHz
2kHz
3kHz
4kHz
6kHz
8kHz
Right
dBHL
Left
dBHL
Step 2. Choose your SPICE Hearing Instrument Models (Style, Product Family, Options)
2.a Choose the Style you like to Order
microBTE/M H2O
BTE
Custom
CRT
Please use separate Phonak CROS order form to order your Phonak CROS transmitter)
2.b Choose which Product Family you want to order
BTE/Custom
R
L
CRT Wireless
R
L
CRT Non-Wireless
R
L
R
L
R
L
Audéo S SMART IX
Phonak Ambra
Ambra nano
Ambra M H2O
Audéo S MINI IX
Naída S IX UP
Naida S CRT IX
Naída S IX SP
Audéo S SMART V
Phonak Solana
Solana nano
Solana M H2O
Audéo S MINI V
Naída S V UP
Nios S H2O V
Naida S CRT V
Naída S V SP
Audéo S SMART III
Phonak Cassia
Cassia M H2O
Audéo S MINI III
Naída S III UP
Nios S H2O III
Naida S CRT III
Naída S III SP
Audéo S SMART I
2.c If you have chosen microBTE/BTE, please choose the below options
Options
Right Ear
Left Ear
Models/Power Levels (2ccGain/MPO)
--select--
micro M (57dB/132dB)
micro P (60dB/129dB)
M H2O (63dB/131dB)
SP (70dB/133dB)
--select--
micro M (57dB/132dB)
micro P (60dB/129dB)
M H2O (63dB/131dB)
SP (70dB/133dB)
Standard Tube Options
Ear mould
--select--
Soft Full Concha
Soft Half Concha
Soft Canal
Hard Full Concha
Hard Half Concha
Hard Canal
--select--
Soft Full Concha
Soft Half Concha
Soft Canal
Hard Full Concha
Hard Half Concha
Hard Canal
Vent
--select--
Occluded
0.6-0.8 mm
0.9-1.1 mm
1.2 - 1.6 mm
1.7 - 2.2 mm
1.7 - 2.2 mm
3.1-4.5 mm
Open
--select--
Occluded
0.6-0.8 mm
0.9-1.1 mm
1.2 - 1.6 mm
1.7 - 2.2 mm
1.7 - 2.2 mm
3.1-4.5 mm
Open
Slim Tube Options
Earpiece
--select--
Open Dome S
Open Dome M
Open Dome L
Close Dome S
Close Dome M
Close Dome L
Power Dome S
Power Dome M
Power Dome L
--select--
Open Dome S
Open Dome M
Open Dome L
Close Dome S
Close Dome M
Close Dome L
Power Dome S
Power Dome M
Power Dome L
Tube Length
--select--
HE 0-R
HE 1-R
HE 2-R
HE 3-R
--select--
HE 0-R
HE 1-R
HE 2-R
HE 3-R
Housing Color
2.d If you have chosen Custom Products please choose the below options
Options
Right Ear
Left Ear
Shell
--select--
Size 10 CIC Petite
Size 312 (ITC/HS)
Size 13 FS
--select--
Size 10 CIC Petite
Size 312 (ITC/HS)
Size 13 FS
Power Level ( 2cc Gain/MPO)
--select--
M (40dB/109dB)
P (50dB/114dB)
SP (60dB/119dB)
--select--
M (40dB/109dB)
P (50dB/114dB)
SP (60dB/119dB)
Venting ? AOV recommended
Venting
--select--
AOV
Occluded
0.6-0.8 mm
0.9-1.1 mm
1.2 - 1.6 mm
1.7 - 2.2 mm
2.3-3.0 mm
3.1-4.5 mm
Open
--select--
AOV
Occluded
0.6-0.8 mm
0.9-1.1 mm
1.2 - 1.6 mm
1.7 - 2.2 mm
2.3-3.0 mm
3.1-4.5 mm
Open
Wax Management - SmartGuard recommended (Select 2nd choice if canal deemed too small to have SmartGuard)
Wax Management
--select--
SmartGuard
HF3
cerustop
--select--
SmartGuard
HF3
cerustop
Handling Option
--select--
Removal Handle
Raised Volume Control
--select--
Removal Handle
Raised Volume Control
All ITC & FS comes with Standard Volume Control (VC), Program Button (PB), Telecoil (TC), Remote Coil (RC) & EasyPhone (EP).
Remote Coil (RC) is optional for CIC and is possible if size permits. Should you wish to not have any of these options- please specify below.
2.e If you have chosen CRT Products please choose the below options
Options
Right Ear
Left Ear
Receiver
--select--
xS (Standard)
xP (Power)
--select--
xS (Standard)
xP (Power)
Earpiece
--select--
Open Dome S
Open Dome M
Open Dome L
Close Dome S
Close Dome M
Close Dome L
Power Dome S
Power Dome M
Power Dome L
SlimTip
xShell
cShell
--select--
Open Dome S
Open Dome M
Open Dome L
Close Dome S
Close Dome M
Close Dome L
Power Dome S
Power Dome M
Power Dome L
SlimTip
xShell
cShell
Venting
--select--
AOV
Occluded
0.6-0.8 mm
0.9-1.1 mm
1.2 - 1.6 mm
1.7 - 2.2 mm
2.3-3.0 mm
3.1-4.5 mm
Open
--select--
AOV
Occluded
0.6-0.8 mm
0.9-1.1 mm
1.2 - 1.6 mm
1.7 - 2.2 mm
2.3-3.0 mm
3.1-4.5 mm
Open
Receiver Wire length
--select--
0-R
1-R
2-R
3-R
--select--
0-R
1-R
2-R
3-R
Housing Color
Step 3. Choose your Wireless Solutions
PilotOne
myPilot
ComPilot
iCom
TVLink/S
TVLink/iCom Bundle
TV Link S/ComPilot
Step 4. Customer Preference Service
Tick if substitutions for technical reasons are acceptable without approval
Call for approval if changes are required
In case of space problems, please give size priority
In case of space problems, please give options priority
Step 6. Special Instruction