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CAMISHA CUSTOM SHELL ORDER FORM CUSTOMER INFORMATION

PATIENT INFORMATION

Bill-to Account Number: _______________________________________________

Date:______________________________________________________________

Ship-to Account Number: ______________________________________________

First Name: _________________________________________________________

Address: ___________________________________________________________

Last Name: _________________________________________________________

P.O. #: _____________________________________________________________

Pediatric Order:

City: _____________________________________State:_____ Zip: ___________

If no vent option is selected on this order form, Widex will select the appropriate vent based on the Audiometric Data provided.

Contact Name: ______________________________________________________ Phone: ______________________________ Email: ________________________ SELECT SERVICE (Must complete)

Audiometric Information Widex may change from hard to soft material to accommodate your order request. Would you like to be consulted before this change is made?* Widex may decrease the vent size to accommodate your order request. Would you like to be consulted before this change is made?*

*This may impact turn around time.

If no service selected, Widex will only process the custom shell order. No receiver will be sent. Indicate hearing aid/device in use: __________________ __________________ Custom shell only. Proceed to Steps 1 and 2. Custom shell pre-assembled to wired receiver. Proceed to Steps 1 and 2. Custom shell pre-assembled with hearing aid or CROS. Proceed to Steps 1, 2, 4 thru 7. Instant ear-tip with hearing aid or CROS. Proceed to Steps 3 thru 7. Use previous CAMISHA scan(s) to manufacture this order. Right Serial #: ____________________ Left Serial #: ____________________

Age: ________________________________________

250Hz

500Hz

1kHz

(Required)

2kHz

3kHz

4kHz

Right Left

Fitting Date: ________________________________________________________ RITE custom shell orders only: If this order is within 90 days of the BTE invoice/patient fit date, provide the BTE serial numbers. Right Serial #: _______________________ Left Serial #: _____________________

NOTE: See Widex Price & Policy Guide for price information.

STEP 1: SELECT CUSTOM SHELL TYPE (Proceed to Step 3 if instant ear-tip is desired.)

Standard

Canal Lock

Extended Canal Lock

D.

E.

F.

Concha Lock

Half Skeleton Lock

G.

Skeleton Lock

H.

Helix Lock

Full Shell Lock

RITE

C.

MODULAR RIC

B.

EMBEDDED RIC

RIC/THIN TUBE

A.

(Not available for “soft” design)

STEP 2: SELECT A CUSTOM SHELL OPTION Design

Hard Solid

(Extended ear-tip)*

S M P

Open Hard

Thin Tube:

Hard Hollow RIC/THIN TUBE

Receiver/Thin Tube Size

(For S&M receivers only)

Soft

Material/Color Hard Clear

(Flex Hard Solid Shell only available in Hard Clear)

0.9mm 1.4mm élan Tube

Hard Beige Hard Medium Brown Soft Clear

(DREAM9 BTE only)

*Not available for élan tube

RECEIVER-IN-THE-EAR (RITE) EARMOLD

Hard 3/4*

Receiver HP SP

Beige Medium Brown Clear

Wired HP

Clear

Trench: No Vent XS S M L XL Max Vent

(For SUPER only)

(For FUSION only)

Wired SP

(For SUPER only)

BABY440

(For BABY440 only)

MODULAR/EMBEDDED

Design Modular Hard

Venting

Material/Color

*With Straight Bore - Standard

Embedded Hard

No Vent XS S M L XL XXL Max Vent Open

Straight: No Vent XS S M L XL Max Vent

Hard Full*

Soft Full

Straight: Trench (For Soft Shell Only):

(No venting needed)

Design Hard 1/2*

Venting

May vary due to ear canal size

Receiver S M P HP SP

(For SUPER only)

(For HP/SP, impression length must include 2nd bend)

Material/Color Hard Clear (Standard)

Soft Hypoallergenic Coat (Hard only) Hard Hypoallergenic Coat (Hard only) Nano Hypoallergenic Coat (Soft only) Retention Ring Thick Removal Line

Wire/Thin Tube Length R

L

0 1 2 3 4

0 1 2 3 4

(Removal string added as standard)

Additional Options Output Extender

Hypoallergenic Coat No Helix Retention Ring

(Hard Shell only)

Soft Hypoallergenic Coat Hard Hypoallergenic Coat Removal Notch Removal Line Retention Ring

Venting Straight: No Vent XS S M L XL XXL Max Vent

Additional Options

Additional Options Soft Hypoallergenic Coat Hard Hypoallergenic Coat Retention Ring Removal Line Thick Removal Line If requesting Canal lock, indicate lock choice from options B-H in Step 1 ____________ ____________

Wire/ Length R

L

-2 -1 0 1 2 3 4 5

-2 -1 0 1 2 3 4 5

(Sizes -1 and -2 only available for BABY440)

Wire/ Length R

L

-1 0 1 2 3 4 5

-1 0 1 2 3 4 5

(-1 and 5 only available for modular)


STEP 3: SELECT INSTANT EAR-TIP (Please complete ONLY if no custom shell has been selected.)

INSTANT

Receiver/Thin Tube Size

Wire/Thin Tube Length

Instant Ear-Tip RIC and Thin Tubes Open

S M P

Round Tips

Double

Tulip

Thin Tube: 0.9mm 1.4mm élan Tube

XS

S

S

L

(Open ear-tip not available for P receiver)

M

One Vent Two Vent

(DREAM9 BTE only)

L

One Vent Two Vent

XS

S

M

Select Level

EVOKE

as Fusion 2)

FUSION2

FUSION

(312 RIC 2.4)

Platinum (Standard)

PASSION

(312 RIC)

FASHION

(10 RIC)

(13 BTE)

(ZEN Standard in all models)

BEYOND Z

440

330

220

BEYOND

440

330

220

Gold

Transparent

FASHION POWER

(312 BTE)

L

STEP 5: SELECT MIC GRID (Fusion2, FUSION and PASSION only)

Select Model

440 330 220 110* (*110 not available

M

L

0 1 2 3 4

One Vent Two Vent

STEP 4: SELECT HEARING INSTRUMENT Select Product

L

R

0 1 2 3 4

Note: N/A for EVOKE Autumn Beige, Silver Grey, Titanium Grey and Tech Black. Default is matching mic grid color.

FUSION2 Z (ZEN Standard)

FUSION2

STEP 6: SELECT ACCESSORIES (Indicate quantity)

(ZEN Standard)

UNIQUE

440 110

330

220

FUSION FASHION MINI

PASSION FASHION POWER

FASHION

PASSION 9 BTE

FASHION

RC2-DEX:

(ZEN Standard in all models)

DREAM

440 110

330

220

FUSION m-Micro (ZEN Standard in all models)

CROS

N/A

FUSION

(Not compatible with Fusion2 or CICm styles)

BABY440

N/A

SUPER

440

FASHION

BABY440 220

SUPER220 VS SUPER220 VSD

SUPER440 VS SUPER440 VSD

(ZEN:

Black _______ FM+DEX:

Silver _______

COM-DEX Remote Mic: Grey ________ CALL-DEX:

)

(ZEN:

Black _______

White _______ ADD’L TV-DEX BASE: Silver _______ Grey ________ TV-DEX: Silver _______ Green _______ PHONE-DEX: Silver _______

COM-DEX:

(DREAM9 BTE only)

Silver _______ UNI-DEX:

Black _______

)

(ZEN Standard in 440 only)

STEP 7: SELECT HEARING AID COLOR 119

Products

121

123

Silver Titanium Aut. Grey Grey Beige

118

136

Tech Black

Deep Blue

069

070

071

081

Capp. Brown

Tan Silk

072

073

074

112

Winter Silver

Titan Grey

Mdnt. Black

Silver White

068

077

090

075

Pearl Metallic Shocking Lime Blue Pink Green White

076

078

Sporty Red

Med. Turq.

LE ILAB AVA E 2018 JUN

EVOKE FUSION2 EVOKE FUSION EVOKE PASSION EVOKE FASHION EVOKE FASHION POWER

021

Warm Summer Cop. Beige Gold Brown

BEYOND Z FUSION2

*

*

*

*

*

*

*

*

*

*

*

*

*

BEYOND FUSION2 UNIQUE FASHION MINI UNIQUE FASHION POWER UNIQUE FUSION DREAM FUSION UNIQUE PASSION DREAM PASSION UNIQUE FASHION DREAM FASHION CROS FUSION CROS FASHION DREAM m-SERIES DREAM 9 BTE 068

084

085

Pearl White

Pearl Pink

Pearl Blue

*Color available Q1, 2018

SUPER Black

Brown

Charcoal Grey NOTE: See Widex Price & Policy Guide for price information.

Order online at widexPRO.com

DFM58_0618

BABY440

DFM58_0618 Custom Camisha Shell Order Form  
DFM58_0618 Custom Camisha Shell Order Form