Venture Custom Ear Piece Order Form
Step 1: Customer Information
Step 2: Patient Information
Ship To Account Number:
Last Name:
Address:
First Name:
City: State: Zip:
Age:Gender:
Bill To Account Number:
Audiogram (Required for AOV):
Third Party Patient Number:
Hz
Date:
Left:
Purchase Order Number:
Right: AC
250
500
1K
2K
3K
4K
AC
Contact Name:
Step 3: HI Warranty
Phone:
Email:
q 2nd year
q 3rd year
/
q 4th year
Rush Options
/
q 24-hour Service ($49.95)
Step 4: Hearing Instrument Selection
If you would like to purchase a hearing instrument at this time, please select below. If not, please proceed to Step 5.
RIC
q 90 (Premium)
Qty
q 70 (Advanced)
q 50 (Standard)
Instrument
______
q 30 (Essential)
01
Instrument Style
Phonak Audéo V
Phonak Audéo V color choice
Beige
10
312
312T
13
q
q
q
q
P5
Champagne
P1
Sand Beige
P6
Silver Gray
P2
Amber Beige
P7
Graphite Gray
P3
Sandalwood
P8
Velvet Black
P4
Chestnut
P9
Ruby
Q1
Petrol
 Specify color choice: __________________
Step 5: Custom Ear Piece Selection
RIC
Side
L
Shell Styles
Power Level
R
Gain/Output (2cc)
xS
xP
xSP plus
45/112
55/126
65/133
q
N/A
N/A
q
q
SlimTip Soft
q
q
SlimTip Hard
q
q
N/A
q
q
cShell Soft
q
q
N/A
q
q
cShell Hard
q
q
q
 Receiver Length (0-3): R ____
SlimTip Hard
SlimTip Soft
cShell Hard
cShell Soft
cShell Hard XL
(HS/FS)
L ____
1.
2.
3.
4.
5.
Make sure you are using the Phonak tool
Make sure Receiver length measuring tool is parallel to the floor
(straight on top of the ear)
Do not apply pressure to the tool (let it sit on the ear)
Use block colors to determine size (if on the line, use the smaller size)
Measure to the top of the ear canal opening
Phonak LLC • 4520 Weaver Parkway • Warrenville, IL 60555 • Fax (630) 393-9858
INTERNAL USE ONLY
S B R1 R2 L1 L2
PNK BLU YLW FLS GRN PRP WHT TRQ
Measuring Tips:
Step 6: Ear Piece Options
N/A
= Not Available
Faceplate Color Options
Shell Color Options
Shell Color:
Shell Styles:
Pink
L
q
q
q
Tan
R
L
N/A
q
Std.
cShell Soft
cShell Hard
L
N/A
SlimTip Soft
SlimTip Hard
Cocoa
R
q
q
L
N/A
q
N/A
q
Brown
R
q
N/A
q
q
L
R
N/A
q
Shell Styles:
q
N/A
q
q
R
N/A
q q
(Std.)
q
q
Faceplate Color:
Std.
N/A
q
Other*
L
Transparent
R
Pink
L
L
q
q
Std.
cShell Soft
q
cShell Hard
q
Cocoa
R
Tan
R
L
q
q
N/A
Brown
R
L
R
q
q
N/A
N/A
q
N/A
q
q
q
* Other color options: Red, Blue, Go Green, White, Light Pink, Light Blue, Licorice, Sunflower & Purple Haze
Specify Other color choice: __________________________________________
Shell Options
Shell Options:
Venting Options
Canal Lock*
(chargeable)
Extra
Retention
Shell Styles:
L
R
L
R
SlimTip Hard
q
q
q
q
cShell Hard
q
q
Extra
Large
L
R
Shell Styles:
N/A
q
N/A
AOV
(Audiogram
required)
Venting:
q
*Transparent, Pink, Cocoa, Tan & Brown shells only
Shell Styles:
R
L
2.0 mm
SAV
2.5 mm
SAV
3.0 mm
SAV
R
L
R
L
R
L
q
q
q
R
Customized
Large Vent
L
R
q
q
Cavity
Vent
L
R
No Vent
L
R
q
q
q
q
SlimTip Soft
q
q
q
q
q
SlimTip Hard
q
q
q
q
q
q
q
q
q
q
q
q
cShell Soft
q
q
q
q
q
q
q
q
q
q
q
q
N/A
q
q
cShell Hard
q
q
q
q
q
q
q
q
q
q
q
q
N/A
q
q
Wax Prevention
Wax Options:
L
Pressure
Vent
(Std.)
(Std.)
(Std.)
N/A
N/A
q
q
(Std.)
Removal Line Options
Wax Trap
(chargeable)
L
R
Extended
Receiver
Tube
L
R
Spring Guard
L
R
Smart
Guard 3
(chargeable)
L
R
SlimTip Hard
(w/Extra Retention only)
q
q
q
q
q
q
q
q
cShell Soft
q
q
q
q
q
q
q
q
cShell Hard
q
q
q
q
q
q
q
q
Color Options:
L
R
Transparent (Std.)
q
q
Tan/Pink
q
q
Brown/Cocoa
q
q
No Removal Line
q
q
**Only available on xS receiver
q
q
q
q
Conversation Set (ComPilot Air II/RemoteMic)
Entertainment Set (ComPilot II/TVLink II)
ComPilot Air II
ComPilot II
Step 9: Special Instructions
Step 8: Preferences
q TVLink II
q RemoteMic
q PilotOne II
If necessary, may we change the following:
Yes
N0
q
q
q
q
q
Please call
xSP plus to xP OR xP to xS if audiogram permits
cShell xSP plus can be built as half shell if required
027-0187-03/2014-10/Printed in USA © All rights reserved
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