CUSTOM IM AND IP ORDER FORM CUSTOMER INFORMATION
PATIENT INFORMATION
Bill-to Account Number: _______________________________________________
Date:______________________________________________________________
Ship-to Account Number: ______________________________________________
First Name: _________________________________________________________
PO #: _____________________________________________________________
Last Name: _________________________________________________________
Address: ___________________________________________________________
Audiometric Information If no vent option is selected on this order form, Widex will select the appropriate vent based on the Audiometric Data provided.
City: _____________________________________State:_____ Zip: ___________ Contact Name: ______________________________________________________ Phone: _________________________ Email: _____________________________ IMPRESSION RECOMMENDATIONS
500Hz
250Hz
1kHz
(Required)
2kHz
3kHz
4kHz
Right Left
Use silicone impression material.
Widex may decrease the vent size to accommodate your order request. Would you like to be consulted before this change is made?
Make impressions past the second bend. For optimal microphone placement, it is recommended to draw a horizontal line through the tragus on the earmold impression.
Use previous CAMISHA impression scan(s) to manufacture this order.
Widex may change your selected sides for the volume control and program button features. Would you like to be consulted before this change is made? Previous User:
Age:___________
Ear Texture:
Soft
Impression:
Open mouth
Medium
Right Serial #: ___________________________
Firm Closed mouth
Left Serial #: ___________________________
SELECT CUSTOM ITE OPTIONS Model
Design
EVOKE440 EVOKE330 EVOKE220 EVOKE110
Hearing Instrument Colors Beige Medium Brown Dark Brown Clear
Canal Half Shell Full Shell
(If Clear shell is chosen, select a faceplate color)
ZEN Program comes standard in all EVOKE and UNIQUE models. (RC-Coil included. T-Coil not included. 312 battery standard.)
Feature*
Receiver EU-IM (85 dB) EU-IP (90 dB)
Beige Medium Brown Dark Brown
Volume Control Program Button
Venting
May vary due to ear canal size
Additonal Options Soft Hypoallergenic Shell Coat Hard Hypoallergenic Shell Coat (Default) Retention Ring Removal Line Removal Notch Canal Lock
IROS Vent Semi IROS Vent Reverse Horn Vent Trench Vent Pressure Vent Largest Vent Possible No Vent XS S M L XL
WARRANTY OPTIONS FOR ALL CUSTOMS (See EVOKE Price List for price information.) OPTIONAL WARRANTIES
EVOKE440/330 3-Year Repair Warranty 3-Year Loss & Damage Coverage (Standard) EVOKE220 2-Year Repair Warranty 2-Year Loss & Damage Coverage (Standard) EVOKE110 1-Year Repair Warranty 1-Year Loss & Damage Coverage (Standard)
2nd Year Repair Warranty 3rd Year Repair Warranty 2nd Year of Loss & Damage Coverage 3rd Year of Loss & Damage Coverage
Wax Guard
No Helix - 3/4 Shell
NanoCare™ (Standard)
Extended Receiver Tubing Spring
SELECT ACCESSORIES (Indicate quantity)* RC2-DEX:
COM-DEX:
3rd Year Repair Warranty 3rd Year of Loss & Damage Coverage
Medium (Standard) Short Long As Marked on Impression
(N/A - Full and Half Shell)
*To optimize size and ease of use, Widex recommends NOT adding a push button and volume control on both ears.
INCLUDED WARRANTIES
Canal Length
Silver ________
UNI-DEX:
Black ________
Black ________
FM+DEX:
Silver ________
White ________
TV-DEX:
Silver ________
Grey _________
ADD’L TV-DEX BASE: Silver ________
Green ________ COM-DEX Remote Mic: Grey _________
PHONE-DEX: Silver ________ CALL-DEX:
Black ________
*All DEX devices are billable items for IM/IP models.
Additional Comments / Special Instructions:__________________ _____________________________________________________ _____________________________________________________ _____________________________________________________
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