Comfort Fit Custom Order Form Patient DOB/Age ____________________________
Patient Name_____________________________________________________________ SKIN COLOR
Pink
B i ll T o
Light Brown
Medium Brown
Dark Brown
Date ___________________
Black
Account No.
Ship To
Account No.
Contact___________________________________ Cell # ________________________
Contact__________________________________________________________________
Email______________________________________ Fax __________________________
Email____________________________________ Fax ___________________________
Check No._____________
Amount_______________
P.O. No._______________
Previous User
YES
NO
RIGHT Previous User
YES
NO
LEFT
HEA R ING AID O R DE R R EQUI R E M ENTS M ODE L
L R LOOK Premier
H e a r i n g E VA L a n d h e a r i n g H i s t o r y
L R LOOK Pro
Output/Make
L R LOOK Prestige
Previous Vent Size
L
Gain/Model
R Serial No. (If NuEar)
STY L E Op t i o n s
L R Directional In-The-Ear L R Half Shell
R e q u e s t e d M at r i x c o o r d i n at e s
L R In-The-Canal L R Completely-In-Canal
L SSPL________
A d d i t i o n a l Op t i o n s Real ear ready
Induction coil (Not available in CIC) L Left R Right
MCL (Most Comfortable Level) __________
___________
____________
UCL (Uncomfortable Level)
___________
____________
125
L R Tall/Stacked VC* *Not available on CIC
L R Light Brown L R Dark Brown*
REMOVAL & FINISH Options L R Removal Notch
*Clear shell is default if selected
(Not available on CIC)
L R Removal Handle L R Dull/Matte Finish
S h e ll Op t i o n s
1000
2000
4000
8K
10 20 30 40
L R Clear L R Blue/Red
L R Extended Receiver Tube
Venting L R No Vent L R 1 Vent L R 2 Vent
50 60
V ENTING Op t i o n s
70
L R Mini Vent L R Variable Vent L R IROS Vent
L R IROS Open Vent 80 90
Okay to change BATTERY size if necessary w/o phone call Okay to change VENT size if necessary w/o phone call
100
W a rr a n t y Op t i o n s ( r e m a k e / r e pa i r / l o s s & D a m a g e )
2nd Year
500
Wax Prevention (Hear Clear is default)
Shell Color
L R Pink L R Light Brown
__________
0
Fa c e pl at e Op t i o n s
L R Medium Brown* L R Chestnut Brown*
250
L
R Gain________
B
User Controls (Default: No User Control)
L R Continuous Digital VC* L R Push Button (VC or Memory)
R SSPL________
R
Sp e e c h A u d i o m e t r y
YES
Directional ( Not available in CIC) L Left R Right
FACEPLATE Color L R Pink
L Gain________
3rd Year
4th Year
5th Year
110
S e rv i c e Op t i o n s
One Day Service
Same Day Service
W i r e l e s s A c c e s s o r y Op t i o n s
L R SurfLink Media L R SurfLink Advanced Remote
L R SurfLink Intermediate Remote L R SurfLink Basic Remote
Sp e c i a l I n s t r u c t i o n s
Internal use only:
IMP10
IMP15
DO NOT WRITE HERE FACTORY USE ONLY
OF10 Š 2011 NuEar All Rights Reserved 85059-500 11/11 FORM0216-00-EE-NE Rev. A
Comfort Fit Custom Order Form
Impression Instructions 4) Once material is set, remove impression, being sure to break the seal via patient jaw movement and ear manipulation.
1) Using an otoscope, inspect the ear canal for anatomical landmarks and verify it is cerumen free. 2) Place a flattened cotton block lubricated with OtoEase 8 to 10 mm beyond the second bend, near the eardrum.
5) Inspect ear impression – Retake impression if not correct.
3) Place the syringe deep into the ear canal and slowly pull back as the ear canal fills with the silicone impression material.
Impression Reference Instructions At the heart of any good hearing aid fitting is the impression. There is no hearing instrument technology or physical modification that can substitute for a good impression. A good impression that goes beyond the second bend of the ear canal is required for the best patient result. It is best to use a flattened cotton block versus the foam block that takes up space in the ear canal and leaves it under filled with short canals. In short, follow these basic guidelines: 1) Examine the ear to select block size.
4) Wait and remove the impression.
2) Place the flattened block past second bend and examine placement.
5) Inspect your work – Retake impression if needed – Pack impression with order form for shipping FedEx overnight.
3) Inject the material with syringe tip deep in the canal.
Impression Checklist When the impression has been completed, the following points provide a useful checklist to ensure the impression is ready to be sent for production:
Is the helix and antihelix complete?
Is the concha complete?
Does the impression have a smooth finish?
There are no weld marks (caused by the impression
Ensure there are no air, hair, or wax voids.
I s the canal sufficient to define the second
material drying too quickly).
The edges of the folds in the concha should not be
bend of the ear canal?
rounded but well defined — avoid mashing the
Is the tragus portion of the ear clearly defined?
material in the concha against the pinna.
X
X
X
Correct
INCorrect
INCorrect
INCorrect
Canal, concha and helix adequately
Insufficient canal depth. Canal block
filled. Canal block left attached.
not placed deeply enough in the ear.
Slanted, under filled canal due to improper placing of block in ear.
Gaps or weld marks. Overall surface of impression not smooth.
Helix either under filled or pressed out.