2103 GS RIC LT MFi OrderForm MK605350 rC 508

2
*UP receiver only available in Encased earmolds 4a RESOUND STANDARD RIC RECEIVERS AND DOMES RIC Receiver tube length Size L R 0 1 2 3 4 For proper fit, measure from the top of the ear to the top of the ear canal using the ReSound measuring tool. Rechargeable Mini RIC Zinc Air Mini RIC Zinc Air RIC 2.4 GHz wireless L R L R L R ReSound ONE Charger included in order of RT961-DRWC RT961-DRWC RT961-DRW RT962-DRW Battery Lithium-ion rechargeable #312 #13 Program selector Programmable Push button Programmable Push button Multifunction Switch Volume control Programmable Push button Programmable Push button Multifunction Switch RIC receivers (power level) M&RIE � � � � � � � � � � � � � � � � � � � � Low power (LP)� � � � � � � � � � � � Medium power (MP) � � � � � � � High power (HP) � � � � � � � � � � Ultra power (UP) * � � � � � � � � � Color (keychain color) Gold (70) � � � � � � � � � � � � � � � � � Warm Grey (71) � � � � � � � � � � � Espresso (72) � � � � � � � � � � � � � Deep Black (73) � � � � � � � � � � � Bronze (74) � � � � � � � � � � � � � � � Champagne (75) � � � � � � � � � � � Sparkling Silver (76) � � � � � � � Graphite (77) � � � � � � � � � � � � � 3 MODEL AND OPTIONS POWER STD CLOSED Domes Size L R Large Medium Small Tulip Large Medium Small Large Medium Small 4b CUSTOM RIC EARMOLD OPTIONS OR GOVERNMENT SERVICES ORDER FORM RESOUND ONE 1.800.392.9932 FAX 1.888.768.1867 RACHAP ACTIVE DUTY INDIAN HEALTH TRICARE COMMUNITY CARE PROVIDER BILL TO Acc’t #: Office: Address: Address: City/State: Zip: P.O. SHIP TO Acc’t #: Date: Phone: Contact name: Email: Facility: Address: Address: City/State: Zip: 2 SPECIAL INSTRUCTIONS (PLEASE PRINT CLEARLY) Patient name: SSN: LAST: FIRST: Previous user: YES NO Audiogram data: Left air: Bone: LDL: Right air: Bone: LDL: 1 PATIENT DATA 250 500 750 1k 1�5k 2k 3k 4k 6k 8k AVAILABLE DEFAULT

Transcript of 2103 GS RIC LT MFi OrderForm MK605350 rC 508

*UP receiver only available in Encased earmolds

4a RESOUND STANDARDRIC RECEIVERS AND DOMES

RIC Receiver

tube length

Size L R

0

1

2

3

4

For proper fit, measure from the top of the ear to the top of the ear canal using the ReSound measuring tool.

Rechargeable Mini RIC

Zinc Air Mini RIC

Zinc Air RIC

2.4 GHz wireless L R L R L R

ReSound ONE™Charger included in order of RT961-DRWC

RT961-DRWC RT961-DRW RT962-DRW

Battery Lithium-ionrechargeable #312 #13

Program selector Programmable Push button

Programmable Push button

Multifunction Switch

Volume control Programmable Push button

Programmable Push button

Multifunction Switch

RIC receivers (power level)M&RIE � � � � � � � � � � � � � � � � � � � �

Low power (LP) � � � � � � � � � � � �

Medium power (MP) � � � � � � �

High power (HP) � � � � � � � � � �

Ultra power (UP)* � � � � � � � � �Color (keychain color)

Gold (70) � � � � � � � � � � � � � � � � �Warm Grey (71) � � � � � � � � � � �Espresso (72) � � � � � � � � � � � � �Deep Black (73) � � � � � � � � � � �

Bronze (74) � � � � � � � � � � � � � � �

Champagne (75) � � � � � � � � � � �

Sparkling Silver (76) � � � � � � �

Graphite (77) � � � � � � � � � � � � �

3 MODEL AND OPTIONS

POW

ERST

DCL

OSE

D

Domes Size L R

Large Medium

Small Tulip

Large Medium

Small

Large Medium

Small

4bCUSTOM RIC EARMOLD OPTIONS

OR

GOVERNMENT SERVICES ORDER FORM

RESOUND ONE1.800.392.9932 FAX 1.888.768.1867

RACHAP

ACTIVE DUTY INDIAN HEALTH

TRICARE

COMMUNITY CARE PROVIDER

BILL TO Acc’t #:

•• Office:

Address:

Address:

City/State:

Zip: P.O.

SHIP TO Acc’t #:

Date: Phone:

Contact name:

Email:

•• Facility:

Address:

Address:

City/State:

Zip:

2 SPECIAL INSTRUCTIONS

(PLEASE PRINT CLEARLY)

Patient name: SSN:

LAST:

FIRST:

Previous user: YES NO

Audiogram data:

Left air:

Bone:

LDL:

Right air:

Bone:

LDL:

1 PATIENT DATA

250 500 750 1k 1�5k 2k 3k 4k 6k 8k

AVAILABLE DEFAULT

SHELL COLORClear � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Light � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Beige � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Medium � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Dark � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Rose (n/a for Encased) � � � � � � � � � � � � � � � � � � � � � � � � � � � � �EarLusion Light (n/a for Encased)� � � � � � � � � � � � � � � � � � � Espresso (hard only) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Red/Blue (default is Red for right, Blue for left) � � � � � � � �

FACEPLATE COLOR (Encased only)Light � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Beige � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Medium � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Dark � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Espresso � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Anthracite � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Clear � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �

CANAL LENGTHFactory select � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �As marked � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �

VENTINGFactory select � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �MOV (vent modification recommended) � � � � � � � � � � � � � � � � � � �SAV � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Pressure� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �None � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �

VENT MODIFICATIONSemi-IROS � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �IROS � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �

WAX PROTECTION (Encased and hard only)HF3 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �GN Wax Filter (default for Encased) � � � � � � � � � � � � � � � � � � � � �None (default for hard) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �

OPTIONSRemoval cord � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Blue/Red dots � � � � � � � � � � � � � � � � � � � � � � � Size (check):

Patient initials � � � � � � � � � � � � � � � � � � � � � � �

RETENTIONCanal Lock (n/a for Skeleton) � � � � � � � � � � � � � � � � � � � � � � � � �Helix Lock (n/a for Skeleton) � � � � � � � � � � � � � � � � � � � � � � � � � �Skeleton Lock (n/a for Skeleton) � � � � � � � � � � � � � � � � � � � � � �Semi-Skeleton Lock (n/a for Skeleton) � � � � � � � � � � � � � � � � �

PLEASE SEND Air bills Impression mailers

L

L R

MK605350 REV C 2021.03

5 RESOUND WIRELESS ACCESSORIES

($) ReSound Remote Control

($) ReSound Remote Control 2

($) ReSound TV Streamer 2

($) ReSound Phone Clip+

($) ReSound Multi Mic

($) ReSound Micro Mic

($) Additional charge for wireless accessories

ENCASED (n/a for M&RIE)

MICROMOLD

SKELETON

TRUFIT™ IMPRESSION—THE 16/4 RULETake an OPEN JAW impression when:• Ear geometry lacks retention• Patient has severe TMJ movement• Instrument migrates out of ear• Instrument is loose or has feedback

Full helix4mm

16mm

MATERIAL

Hard (acrylic) Soft (silicone)

(n/a for Encased)

L

L

L

R

R

R

L

LLL

R

RRR

L

LL

R

RR

LLLLL

RRRRR

LLLLLLL

RRRRRRR

L

L

L

L

LLLLLLLL

R

R

R

R

R

RRRRRRRR

AVA

ILA

BLE

D

EFA

ULT

SMALL LARGEor

6 EARMOLDS