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)
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
Tulip
Double
Thin Tube:
S
0.9mm
XS
1.4mm
S
M
One Vent Two Vent
L
(Open ear-tip not available for P receiver)
L
One Vent Two Vent
One Vent Two Vent
XS
S
Select Level
EVOKE
440 110
Select Model
330
220 RIC 10
FUSION
(312 RIC)
Platinum (Standard) (13 BTE)
RIC 312 D FASHION (312 BTE) BTE 13 D*
BEYOND
440
330
220 FUSION2
UNIQUE
440 110
330
220 FUSION FASHION MINI
FASHION MINI
FUSION
(Not compatible with 2.4 GHz enabled hearing aids or CICm styles)
BABY440
N/A
L
(ZEN Standard in all models)
TV PLAY:
Transparent
Black________ RC2-DEX:
Direct 2.4 GHz TV streaming (EVOKE RIC 312 D and BTE 13 D only)
TV-DEX: Silver________ ADD’L TV-DEX BASE: Silver________ COM-DEX: White _______ Grey ________
(ZEN Standard)
PASSION FASHION POWER
Gold
STEP 6: SELECT ACCESSORIES (Indicate quantity)
(312 BTE)
FASHION
(ZEN Standard in all models)
N/A
M
Note: N/A for EVOKE Autumn Beige, Silver Grey, Titanium Grey and Tech Black. Default is matching mic grid color.
FASHION POWER
*Note: BTE 13 D available with thin tube in Spring 2020.
CROS
L
L
0 1 2 3 4
STEP 5: SELECT MIC GRID — FUSION2, FUSION, and PASSION (EVOKE FUSION only)
STEP 4: SELECT HEARING INSTRUMENT Select Product
M
R
0 1 2 3 4
UNI-DEX:
FASHION
Green _______ Black _______
Silver________
Black________
COM-DEX Remote Mic: Grey_________ FM+DEX:
Silver________
ZPower Second Generation Retrofit Kit: ____________ (EVOKE RIC 312 D and BEYOND FUSION2)
Assemble ZPower doors at no add’l cost
PHONE-DEX 2: Silver _______ PerfectDry Lux ZPower (EVOKE only) Rechargeable ADD’L PHONE-DEX 2 Dryer: ____________ HANDSET Silver _______ Assemble at no add’l cost (EVOKE only) PerfectDry Lux CALL-DEX: Black _______ Dryer: ____________
BABY440
STEP 7: SELECT HEARING AID COLOR 119
Products
121
123
118
Silver Titanium Autumn Tech Grey Grey Beige Black
136
Deep Blue
021
069
070
071
Warm Summer Copper Capp. Beige Gold Brown Brown
081
072
073
074
112
Tan Silk
Winter Silver
Titan Grey
Mdnt. Black
Silver White
068
090
077
075
Pearl Metallic Shocking Lime Blue Pink Green White
076
078
Sporty Red
Med. Turq.
EVOKE RIC 312 D EVOKE FUSION EVOKE RIC 10 EVOKE BTE 13 D EVOKE FASHION EVOKE FASHION MINI EVOKE FASHION POWER BEYOND FUSION2 UNIQUE FASHION MINI U NIQUE FASHION POWER UNIQUE FUSION UNIQUE PASSION UNIQUE FASHION CROS FUSION CROS FASHION BABY440
NOTE: See Widex Price & Policy Guide for price information. 068
084
085
Pearl White
Pearl Pink
Pearl Blue
NOTES: __________________________________________________________________________________ __________________________________________________________________________________
REMOTE LINK: Silver____________
__________________________________________________________________________________ __________________________________________________________________________________
Order online at widexPRO.com
DFM58/0220
STEP 8: SELECT REMOTE PROGRAMMING (Indicate quantity)