RITE & BTE Earmold Order Form€¦ · White Black ConnectLine Phone 2.0* Remote Control Velox...

Client Services 1-800-263-8700 • Adult: orders@oticon.ca • Pediatric: pedsorders@oticon.ca • www.oticon.ca

RITE Mold Colour

RITE Options

miniFit Receivers L R 0 1 2 3 4 5

miniFIT 60

miniFIT 85

miniFIT 100 n/a

designRITE 80 n/a

100/105 power mold n/a

DomesSize in mm:

5* 6 8 10 12Open n/a

Bass single n/a

Bass double n/a

Power n/a

Corda miniFit Domes

Size in mm:6 8 10 12

Open n/a

Bass single

Bass double

Power

Grip TipL R

Small Large

Vent No vent

RITE Molds Acrylic Silicone

Micromold LiteTip In-Mold Microshell RITE Power Micromold RITE Power

60 60 60 60 100 60 100

85 85 85 85 105 85

80 80 100 80

80

L R

Micromold n/a n/a

Canal* n/a n/a n/a

Canal Lock n/a

Half Shell n/a n/a n/a

Semi Skeleton n/a n/a n/a n/a

Skeleton n/a

Shell n/a n/a n/a

Non-occluding 100/105 receivers cannot be used for non-occluding

Canal Lip* Removal Line

Vent Size: 0.8 1.4 2.4 3.0 No Vent

LiteTip Vent Size 0.7 0.8 1.2 1.5 No Vent

BTE Molds Acrylic Silicone Soft Silicone

L RBTE

Corda miniFit

micromold

Corda miniFit

LiteTipBTE Corda

miniFit BTE

Micromold n/a n/a n/a

Canal

Canal Lock

Half Shell n/a

Semi Skeleton n/a n/a n/a n/a

Skeleton

Non-occluding n/a n/a n/a n/a

Shell n/a

Full Mold n/a

If pre-programming is selected, both audiometric & patient information must be provided in full. Otherwise aid will be shipped at factory settings.

Special Instructions

Earmold Tubing L R

#13 Thin Wall

#13 Standard

#13 Heavy

#13 Super Heavy

#13 Dri

#13 Heavy Dri

Corda miniFit

Tubing Length L R

-1

0

1

2

3

4

Shell __________(See reverse for options)

Faceplate __________(If applicable.)

BTE Mold Colour ____________________________________(See reverse for options)

*5mm for 60 receiver only

Corda miniFit size L R Vent size: 0.8 1.4 1.8 2.4 3.0 No vent

Standard 0.9 mm LiteTip Vent size: 0.7 0.8 1.2 1.5 No vent

Power 1.3 mm* * Not applicable with LiteTip Removal Line

Streamer & ConnectLine Products *Requires a Streamer

Streamer Pro ConnectLine TV 2.0* ConnectLine Microphone*White Black ConnectLine Phone 2.0* Remote Control

Velox Accessories *Devices not backwards compatible

Remote Control 3.0* TV Adapter 3.0* ConnectClip* Phone 2.0

Velox S Charger (miniRITE-R only)

MIS

C-O-

010

/ 02.

19

Choose your RITE or BTE Style: Please check box A or B below

A) I do not need to order the instrument(s) but, I will be fitting the earpiece to: Choose make and model: __________________________________ Indicate attached receivers: ____________________________________

B) I wish to order earpiece AND instrument(s), please include: Choose make and model: L ____________________ R ____________________ Colour: L _______________ R _______________(See reverse for options) (See reverse for options)

Date Order Placed: _ /_ /_

Bill to Account # ___________________________

Name: ______________________________________

Address: ____________________________________

Phone: _____________________________________

Ship to Account # _________________________

Name: ______________________________________

Address: ____________________________________

Phone: _____________________________________

RITE & BTE Earmold Order Form

V012

Patient Information:Name: ______________________________________

Pediatric Date of Birth: _ /_ /_ D D M M Y Y Y Y

Clinician Contact Date Required

Claim # (CSST, DVA, NIHB, WCB, WSIB) Purchase Order #

Please do not write in this space. For manufacturer use only.

Priority Rush: 1 Business Day (in house) $30 Rush: 2 Business Days (in house) $20

Standard delivery is 5 business days at no charge

Please pre-program Please return impressions

RITE and BTE Styles

Inium Sense

designRITE miniRITE RITE miniBTE BTE BTE P PP SP

Alta2 Pro ● ● Ti ● Ti ● ● Ti ● ● n/a

Alta2 n/a ● ● ● ● ● ● n/a

Nera2 Pro ● ● Ti ● Ti ● ● Ti ● ● n/a

Nera2 n/a ● ● ● ● ● ● n/a

Ria2 Pro ● ● Ti ● Ti ● ● Ti ● ● n/a

Ria2 n/a ● ● ● ● ● ● n/a

Dynamo n/a n/a n/a n/a n/a n/a n/a ●

Sensei Pro SP n/a n/a n/a n/a n/a n/a n/a ●

Sensei SP n/a n/a n/a n/a n/a n/a n/a ●

Velox S

miniRITE miniRITE-T miniRITE R BTE PP

Opn S1 ● ● ● ●

Opn S2 ● ● ● ●

Opn S3 ● ● ● ●

Opn Play 1 ● ● ● ●

Opn Play 2 ● ● ● ●

Rise 2

BTE /SP

Sumo DM (675) ●INIUM

WIRELESS

INIUMWIRELESS

Velox

miniRITE miniRITE-T BTE BTE PP

Opn 1 ● ● n/a ●

Opn 2 ● ● n/a ●

Opn 3 ● ● n/a ●

Siya 1 ● ● ● ●

Siya 2 ● ● ● ●

Write your choice on the reverse side

RITE and BTE Colours BTE Earmold Colours Write your choice on the reverse side

Write your choice on the reverse side

All Models miniRITE designRITE Only

Alta2Nera2Ria2

Dynamo

63 Diamond Black92 Steel Grey91 Silver Grey44 Silver90 Chroma Beige94 Terracotta93 Chestnut Brown

47 Cool Blue 95 Vivid Lilac66 Mother of Pearl73 Cabernet Red68 Midnight Blue69 Sunset Orange99 Pale Lime

Opn PlaySensei SP

63 Diamond Black94 Terracotta90 Chroma Beige44 Silver70 Purple

46 Red47 Blue 48 Emerald Green93 Chestnut Brown

57 Power Pink 58 Aquamarine 79 Baby Pink

Classic Colours

Sumo DM

10 Beige11 Light Brown12 Dark Brown

13 Light Gray14 Dark Gray

All Models

Opn S Opn Siya

CO90 Chroma BeigeCO94 Terracotta ▲

CO93 Chestnut BrownCO63 Diamond BlackCO92 Steel Grey

CO68 Royal Blue*▲

CO91 Silver GreyCO44 Silver▲

RITE Molds - Acrylic Colour Selection

Micromold Clear

LiteTip Clear

InMold Shell: Beige (Std), Clear, Red, Blue

Faceplate: Beige (Std), Pink, Med Brown, Dark Brown, Clear

Microshell Shell: Beige (Std), Clear, Red, Blue

RITE Pwr - 100/105 Canal Style: Beige (Std), Clear, Red, BlueOther Styles: Clear (Std), Beige, Red, Blue

RITE Molds - Silicone Colour Selection

Clear

BTE Molds - Acrylic Colour Selection

Clear

BTE Molds - Silicone Colour Selection

Clear, Beige, Green, Blue, Med Brown, Dark Brown, Yellow, White, Red, Lilac, Black, Orange, Flesh Tone, Fluorescent Pink*

*Opn miniRITE only ▲ Not available for Siya

MISC-O-010 / 02.19

*Soft Silicone Only