CAMISHA CUSTOM SHELL ORDER FORM CUSTOMER INFORMATION
PATIENT INFORMATION
Bill-to Account #:_____________________________________________________
Date:______________________________________________________________
Ship-to Account #:____________________________________________________
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
RIC/THIN TUBE
H ard Hollow
Receiver/Thin Tube Size
H ard Solid
(Extended ear-tip)*
S M P
O pen Hard
Thin Tube:
S oft
0.9mm 1.4mm
(For S&M receivers only)
Material/Color Hard Clear
(Flex Hard Solid Shell only available in Hard Clear)
Hard Beige Hard Medium Brown Soft Clear
*Not available for élan tube
RECEIVER-IN-THE-EAR (RITE) EARMOLD
H ard 3/4*
Receiver
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)
M odular Hard
Venting
HP SP
Design MODULAR/EMBEDDED
Material/Color
*With Straight Bore - Standard
E mbedded Hard
No Vent XS S M L XL XXL Max Vent Open
Straight: No Vent XS S M L XL Max Vent
H ard Full*
S oft 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)
Venting Straight: No Vent XS S M L XL XXL Max Vent
Additional Options 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
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)