RACHAP Active Duty Indian Health

Veterans Choice Other __________

___________________

Check if RIC Ordered with Earmolds

Shipping: No charge UPS 2nd DayEarmolds will ship with the RIC when ordered together

GOVERNMENT SERVICES RIC AND EARMOLD ORDER FORMTEL: (800) 955-4327 FAX: (732) 562-6653 EMAIL: va.customercare@sivantos.com

Hearing Thresholds250 Hz 500 Hz 1 kHz 2 kHz 3 kHz 4 kHz 6 kHz 8 kHz

Left Air

Bone

LDL

Right Air

Bone

LDL

P.O. No.

Account #

Last Name, First Name, Middle Initial Patient Information

Bill To Address: Contact: Ship To Address:

Tel:

Email:

Last 4 S.S.#

Date: MM /DD / YY

RIC Receiver Tube Lengths

L R

0 RL

1 RL

2 RL

3 RL

4 (M receiver only) RL

RIC Receiver Power Level

L R

S = 45/108dB RL

M = 60/119dB RL

P = 70/124dB RL

HP = 75/130dB* RL

*HP earmold only

Model Pure® Charge&Go Nx

Pure 312 Nx

Pure 13 Nx

CROS Pure 312 Nx

Hearing instrumentL R L R L R L R

RL RL RL RL

Battery Li-ion 312 13 312

Program selector Push button Rocker Rocker –

Volume control Push button Rocker Rocker Rocker

Color

L R L R

Beige (1) RL Golden Blonde (30) RL

Granite (2) RL Sandy Brown (31) RL

Grey (3) RL Dark Champagne (37) RL

Black (5) RL Dark Granite (66) RL

Silver (6) RL Deep Brown (72) RL

Pearl White (7) RL

Click Sleeves 2.0

L R

Vented xS RL

Vented S RL

Vented M RL

Vented P RL

Closed xS RL

Closed S RL

Closed M RL

Closed P RL

Click Domes

L R

Open 4mm RL

Open 8mm RL

Open 10mm RL

Semi-Open 8-12mm RL

Closed 6mm RL

Closed 8mm RL

Closed 10mm RL

Double 8-10mm RL

Double 10-12mm RL

Accessories (Additional charge for accessories)

Streamline TV Streamline Mic miniPocket™

Li-Ion Portable power supply (Pure Charge&Go only)

Special instructions:

1

2

5a

3 4

5b

6

For internal use only

Aids: 1 2 Earmolds: 1 2 Impression: Yellow Blue Pink Peach White Purple Trans Brown Turq Green Org

Receiver: 1 2 Impressions: 1 2

Charger: 1 2 Remotes: 1 2 RECEIVED = NJ Bag #______________ ID #______________

Copyright © 2018 Signia GmbH. All rights reserved. Part #10536367 11/18 13.0 22B771 500 SI/18696-18

Earmold Style

L R

RIC

RL

Foil RIC RL

Embedded RIC (select receiver also) RL

Canal RIC RL

Half Shell RIC RL

Full Shell RIC RL

RIC with Lock

RL

Foil RIC with Lock RL

Embedded RIC with Lock RL

RIC Helix Lock RL

Canal RIC Lock RL

Skeleton RL

Semi-Skeleton RIC RL

3/4 Skeleton RIC RL

1/2 Skeleton RIC RL

Skeleton Foil RIC RL

Skeleton Open RIC RL

CROS RL

Material

Acrylic – hard RL

Silicone – soft (N/A for HP) RL

Matte or Gloss finish

Clear RL

Rose RL

Beige RL

Brown RL

Silicone with gloss finish(can swirl up to 3 colors)

L R

Red Opaque RL

Orange Opaque RL

Yellow Opaque RL

Blue Opaque RL

Lilac Opaque RL

Black Opaque RL

White Opaque RL

Pink Translucent RL

Blue Translucent RL

Purple Translucent RL

Red Glitter RL

Orange Glitter RL

Yellow Glitter RL

Green Glitter RL

Blue Glitter RL

Purple Glitter RL

Pink Glitter RL

Clear Glitter RL

Canal Length

Factory select option RL

Cut to Mark RL

Full length of impression RL

Venting

Largest Vent Possible RL

Semi-IROS RL

Select-a-Vent 3.0mm RL

Select-a-Vent 2.0mm RL

Standard 1.6mm RL

Pressure Vent 1.0mm RL

Power Vent 1.2mm RL

No Vent RL

Side Indicators(pick only 1 type)

L and R RL

Blue and Red dot RL

Removal String

Add Removal String RL

HP Earmold

HP Shell

Faceplate Color (HP Only)

Beige RL

Mocha RL

Brown RL

Shell Options and Coatings (HP Only)

Digital Canal Lock RL

Clear Coat RL

Red Shell RL

Blue Shell RL

Clear Shell RL

Venting (HP Only)

No Vent RL

Small SAV 1.6mm RL

Pressure Vent 1.3mm RL

Micro Vent 1.0mm RL

Wax Protection (HP Only)

L R

Bell Bore RL

Wax Spring RL

Extended Receiver Tubing RL

GOVERNMENT SERVICES RIC AND EARMOLD ORDER FORMTEL: (800) 955-4327 FAX: (732) 562-6653