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Westone Custom Earpiece Order Form www.westone.com • Colorado Springs: 1.800.525.5071 • Kalamazoo: 1.800.552.7203

Patient Name:________________________

Age:______ Date:_ ________

Note: Please fill out all areas completely, failure to do so may delay your order. Yes, Westone may make necessary changes to an earpiece style or material without contacting me.

Earpiece Style

Dispenser Information Sold To: (The invoice for this order will be sent to this address.)

Earpiece Style # _______ Left Helix Lock 3/4 Shell

___________________________________________________________ ___________________________________________________________

Instrument used:_ __________________ Standard earhook type Slim Tube Fitting Receiver in canal (RIC) fitting

___________________________________________________________

Westone Account No. Colorado Springs

Shipping Code

Kalamazoo P.O. Number

Submitted By:___________________________________________________ Phone:_ _______________________________________ Ext. #:___________

Shipping Instructions Ship To:

Dispenser (use address listed above)

Other Office

Patient

Other Address: _ _________________________________________________

_ _________________________________________________

_ _________________________________________________

Shipping Method (additional charges apply for all FedEx and Rush requests) FedEx Priority Overnight (10:30 a.m. next day) Rush* Priority Overnight order FedEx Standard Overnight (3:00 p.m. next day) Rush* Standard Overnight order * $10 Rush charges apply for each standard earFedEx 2Day (4:30 p.m. second business day) piece made. A flat rush charge of $50 for CR-1 FedEx Express Saver (4:30 p.m. third business day) and RH-1 earphones and $125 for ES musicians’ Standard Shipping (1st Class Mail) monitors is applied for each pair ordered.

Billing Method Westone Account Check or Money Order Enclosed Visa MasterCard American Express

Discover

Card Number:_ ________________________________ Expires: _____________ Signature:_ ____________________________________________________

(Required if using credit card as payment method)

Special Requests / Information

(If remake–full explanation along with invoice and earpiece number required.)

_______ Right

Earpiece Materials and Colors

This Area For Westone Use

Hearing Loss Mild Moderate Severe Profound Please Complete Audiogram

Silicone OtoBlast™ Single Color Color #1____________ Swyrl Colors Color #2____________ Color #3____________ Cat Eyes Color: Clear &_ __________ DisappEar A B C Glitter Color(s) _______________ w/E-Compound

W-1 Single Color/tone_ ______________ DisappEar™ A B Glitter Color(s) _______________ w/E-Compound™

AquaNot™ Swim plugs Single Color Color #1____________ Swyrl Colors Color #2____________ Color #3____________ Vinyl Formula II (light tan) or Lt. Brown Md. Brown_ Dk. Brown Neon Color_ ___________ Formula II Clear Tint_ ___________ Superflex RX (medium tan) or Lt. Brown Md. Brown Dk. Brown Marble Color: White &_____________ Acrylic Clear Tint Light Pink Beige Lt. Brown Md. Brown Dk. Brown Single Color Color #1____________ Swyrl Colors Color #2____________ Color #3____________ DisappEar A B C Glitter Color(s) _________________

Use back for additional notes

This Area For Westone Use Earpiece Info

Additional Acrylic Canal Options: Flex Canal E-Compound FIT™ Technology* Clear Rose - Transparent Brown - Transparent Brown - Opaque Beige - Opaque * FIT Technology includes scanning and storing ear impressions digitally for a minimum of 2 years.

Print Form

Reset Form

Left Ear-X

Right Ear-O

Venting Options Vent size (select one) Pressure: Standard: Medium: Large: MVP SAV* Largest vent possible No vent

Metric Decimal 1.0mm .040” 1.6mm .063” 2.0mm .081” 2.4mm .096” (all sizes included) (all sizes included)

Semi-Iros – approx. 1/2 of lower canal tip removed. Not available on all styles. *SAV will be included if space allows, otherwise the MVP may be substituted.

Tubing Options Factory select or Tube size #________ DisappEar Tubing Dry Tube Tube Through (if size permits) CFA-Audiogram #_ ________________ No Tube (slim tube or R.I.C. fitting) Canal Length Short Medium As marked on impression

Long

Miscellaneous Information Finish: Matte Finish High Gloss (shiny) Nylon Cord (default black) or Color __________ Handle(s) Removal Filament(s) Patient’s initials__________(3 Max.) Please send me more: Order Forms Impression Boxes ©Westone Laboratories, Inc. Form 751-02-06 Rev B PN 49911 06/08

Westone Order Form  

Standard order form for Westone products

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