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MICROTECH WIRELESS CUSTOM ORDER FORM
HIGHLIGHTED / GREEN AREAS MUST BE COMPLETED FOR APPROPRIATE MATRIX SELECTION
STEP 1 - ORDER
ORDER
BILL TO:
SHIP TO:
ACCOUNT NUMBER:
ADDRESS:
ACCOUNT NUMBER:
ADDRESS:
CONTACT:
PHONE:
P.O. NO.
CONTACT:
CHECK NO.
AMOUNT
PHONE:
SERVICE OPTIONS (ADDITIONAL CHARGES APPLY)
SAME DAY SERVICE
AGREEMENT TYPE
AGREEMENT STATE
REFERENCE #
ONE DAY SERVICE
WARRANTY OPTIONS (REPAIR/LOSS & DAMAGE)
2ND YEAR
(THRIVE w10, PROPEL w10
& AVAIL w10 ONLY)
3RD YEAR
4TH YEAR
5TH YEAR
STEP 2 - PATIENT
FIRST
NAME
LAST
NAME
TEST DATA
MCL L:
MCL R:
PATIENT DOB/AGE
UCL L:
DATE
HEARING AID HISTORY
UCL R:
Air
RIGHT
Bone
LEFT
PREVIOUS USER
YES
NO
PREVIOUS VENT SIZE
RIGHT
PREVIOUS USER
YES
NO
L:
R:
Frequency
2505007501K2K 3K4K 6K8K
OUTPUT/MAKE
Air
LEFT
Bone
GAIN/MODEL
SERIAL NO. (IF MICROTECH)
STEP 3 - PRODUCT (BOLD INDICATES THE DEFAULT)
STYLE OPTIONS
MODEL
FACEPLATE/SHELL OPTIONS (CHOOSE ONE)
IN-THE-EAR*
THRIVE w50
PROPEL w20
HALF SHELL
THRIVE w40
PROPEL w10
PINK/PINK (ITE-ITC)
BLUE/RED
IN-THE-CANAL
THRIVE w30
MOBILITY 50
LIGHT BROWN/LIGHT BROWN
CLEAR
COMPLETELY-IN-CANAL
THRIVE w20
MOBILITY 40
DARK BROWN/CLEAR
THRIVE w10
MOBILITY 30
MEDIUM BROWN/CLEAR (CIC)
PROPEL w50
AVAIL w20
CHESTNUT BROWN/CLEAR
CHARGEABLE OPTIONS
PROPEL w40
AVAIL w10
DIRECTIONAL
PROPEL w30
*PROPEL/AVAIL WIRELESS ITE
IS DIRECTIONAL ONLY
FACEPLATE/SHELL COLOR
OPTIONAL SHELL COLOR
WAX PREVENTION
HEAR CLEAR
EXTENDED RECEIVER TUBE
REMOVAL & FINISH OPTIONS
(NOT AVAILABLE IN CIC)
REMOVAL NOTCH
REMOVAL HANDLE
DULL/MATTE FINISH
CANAL LOCK*
(NOT AVAILABLE IN CIC)
INDUCTION COIL
(NOT AVAILABLE IN CIC)
*NOT AVAILABLE IN ITE
VENTING OPTIONS
USER CONTROLS (CHOOSE ONE)
NO USER CONTROL
FACTORY SELECT
MINI VENT
DIGITAL ROTARY VC*
NO VENT
VARIABLE VENT
PUSH BUTTON (VC OR MEMORY)
1 VENT
IROS VENT
DIGITAL ROTARY VC +
MEMORY BUTTON**
2 VENT
WIRELESS ACCESSORIES
SURFLINK MOBILE 2
SURFLINK REMOTE BASIC
SURFLINK MEDIA
SURFLINK REMOTE INTERMEDIATE
SURFLINK REMOTE ADVANCED
VC OPTIONS
STACKED VC
SPECIAL INSTRUCTIONS:
*NOT AVAILABLE IN CIC
**AVAILABLE FOR THRIVE AND PROPEL ONLY
REFERENCE #: ____________________
DO NOT WRITE HERE
FACTORY USE ONLY
© 2014 MicroTech Hearing Technologies. All Rights Reserved. 85016-004 12/14 FORM0211-05-EE-MT
MICROTECH NON-WIRELESS CUSTOM ORDER FORM
HIGHLIGHTED / GREEN AREAS MUST BE COMPLETED FOR APPROPRIATE MATRIX SELECTION
STEP 1 - ORDER
ORDER
BILL TO:
SHIP TO:
ACCOUNT NUMBER:
ADDRESS:
ACCOUNT NUMBER:
ADDRESS:
CONTACT:
PHONE:
P.O. NO.
CONTACT:
CHECK NO.
AMOUNT
PHONE:
SERVICE OPTIONS (ADDITIONAL CHARGES APPLY)
SAME DAY SERVICE
AGREEMENT TYPE
AGREEMENT STATE
REFERENCE #
ONE DAY SERVICE
WARRANTY OPTIONS (REPAIR/LOSS & DAMAGE)
2ND YEAR
(PROPEL 10 &
AVAIL 10 ONLY)
3RD YEAR
4TH YEAR
5TH YEAR
STEP 2 - PATIENT
FIRST
NAME
LAST
NAME
TEST DATA
MCL L:
MCL R:
PATIENT DOB/AGE
UCL L:
DATE
HEARING AID HISTORY
UCL R:
Air
RIGHT
Bone
LEFT
PREVIOUS USER
YES
NO
PREVIOUS VENT SIZE
RIGHT
PREVIOUS USER
YES
NO
L:
R:
Frequency
2505007501K2K 3K4K 6K8K
OUTPUT/MAKE
Air
LEFT
Bone
GAIN/MODEL
SERIAL NO. (IF MICROTECH)
STEP 3 - PRODUCT (BOLD INDICATES THE DEFAULT)
STYLE OPTIONS
FACEPLATE/SHELL OPTIONS (CHOOSE ONE)
MODEL
VENTING OPTIONS
IN-THE-EAR
PROPEL 50
FACTORY SELECT
HALF SHELL
PROPEL 40
NO VENT
PINK/PINK (ITE-ITC)
BLUE/RED
IN-THE-CANAL
PROPEL 30
1 VENT
LIGHT BROWN/LIGHT BROWN
CLEAR
COMPLETELY-IN-CANAL
PROPEL 20
2 VENT
DARK BROWN/CLEAR
PROPEL 10
MINI VENT
MEDIUM BROWN/CLEAR
FOCUS 50
VARIABLE VENT
CHESTNUT BROWN/CLEAR
FOCUS 40
IROS VENT
CHARGEABLE OPTIONS
DIRECTIONAL
(NOT AVAILABLE IN CIC)
INDUCTION COIL
(NOT AVAILABLE IN CIC)
FACEPLATE/SHELL COLOR
OPTIONAL SHELL COLOR
WAX PREVENTION
HEAR CLEAR
EXTENDED RECEIVER TUBE
REMOVAL & FINISH OPTIONS
FOCUS 30
AVAIL 20
REMOVAL NOTCH
REMOVAL HANDLE
DULL/MATTE FINISH
CANAL LOCK*
(NOT AVAILABLE IN CIC)
AVAIL 10
*NOT AVAILABLE IN ITE
USER CONTROLS (CHOOSE ONE)
NO USER CONTROL
DIGITAL ROTARY VC*
DIGITAL ROTARY VC + MEMORY BUTTON*
ANALOG VC
ANALOG ROTARY VC +
MEMORY BUTTON*
PUSH BUTTON (VC OR MEMORY)
VC OPTIONS
STACKED VC
SPECIAL INSTRUCTIONS:
*NOT AVAILABLE IN CIC
REFERENCE #: DO NOT WRITE HERE
FACTORY USE ONLY
© 2014 MicroTech Hearing Technologies. All Rights Reserved. 85016-004 12/14 FORM0211-05-EE-MT