Date Order : *   Date Required : *
PO/Indent No :   Hearing Clinic : *
Client Name:  *   Client ID :
Age :   
Ordered By: *   Contact Phone:  *
Contact Email ID:  *
 
Binoural Order    Monoural Order
 
 
Step 1. Enter the Audiogram - Air Conduction only. (Required for AOV)
Ear 250Hz 500Hz 750Hz 1kHz 2kHz 3kHz 4kHz 6kHz 8kHz  
Right dBHL
Left dBHL
 
Step 2. Choose your Belong Instrument Models (Style, Product Family, Options)
 
2.a Choose the Style you like to Order
 
BTE    Custom    RIC 
 
2.b Choose which Product Family you want to order
 
Bolero B    Bolero BR    Naida B    Sky B    Sky BR 
Vitro B    Vitro B Titanium 
Audeo B    Audeo BR    Audeo B Direct    Naida BR    Sky B 
BTE R L
Custom R L
RIC R L
BTE R L
Custom R L
RIC R L
BTE R L
RIC R L
Bolero B90
Bolero B50-PR
Virto B90
Audeo B90
Audeo B90 Direct
Audeo B90 – R
Naida B90
Virto B90 Titanium
Naida B90 R
Sky B90
Sky B90 PR
Sky B90
Bolero B70
Bolero B70-PR
Virto B70
Audeo B70
Audeo B70 Direct
Audeo B70 – R
Naida B70
Virto B70 Titanium
Naida B70 R
Sky B70
Sky B70 PR
Sky B70
Bolero B50
Bolero B90-PR
Virto B50
Audeo B50
Audeo B50 Direct
Audeo B50 – R
Naida B50
Naida B50 R
Sky B50
Sky B50 PR
Sky B50
Bolero B30
Virto B30
Audeo B30
CROS BR
Naida B30
Cros B 312
Cros B 312
Cros B 312
Custom Cros B312
Cros B 312
Cros B 312
Cros B 13
Cros B 13
Cros B 13
Custom Cros B13
Cros B 13
Cros B 13
2.c Please choose the below options
  Options Right Ear Left Ear
  Power Level
  Standard Tube Options
  Ear mould
  Vent
  Slim Tube Options
  Dome Sizes
  Tube Length
  Housing Color
  Options Right Ear Left Ear
  Shell
  Power Level
  Omni / Directional
  Wireless / Non-wireless
  Venting
  Venting
  Wax Management - SmartGuard recommended (select 2nd choice if cancel deemed too small to have SmartGuard)
  Wax Management
  Handling Option
  Options Right Ear Left Ear
  Battery Sizes
Note:

1) Options for Virto B Titanium nano:
   With Mini Control
   Without Mini Control

2) Options for Virto B Titanium Size 10A CIC:
   Standarad Configuration: Program Button(PB) + Telecoil(TC)
   Program Button(PB)
   Telecoil(TC)

  Titanium Nano
  Virto B Titanium Nano
  Virto B Titanium Size 10A CIC
2.d If you have chosen Custom Products please choose the below options
  Options Right Ear Left Ear
  Shell
  Power Level ( 2cc Gain/MPO)
  Venting
  Venting
  Wax Management - SmartGuard recommended (Select 2nd choice if canal deemed too small to have SmartGuard)
  Wax Management
  Handling Option
2.d If you have chosen RIC Products please choose the below options
  Options Right Ear Left Ear
  Receiver
  Earpiece
  Venting
  Receiver Wire length
  Housing Color

*xUP is not available for Audeo B-10 model.

Step 3. Choose your Wireless Solutions
 
PilotOne II EasyCall II DECT Phone II ComPilot Air II
ComPilot II TV Link II ComPilot II + TV Link II Bundle
 
Step 4. Customer Preference Service Step 3. Customer Preference Service
 
Please change options for better techinical performance.
In case of space constraint, please give size priority.
In case of space constraint, please give options priority.
Please contact me for approval of any changes.
 
Step 5. Pediatric Kit Step 4. Pediatric Kit
 
Do you require a pediatric kit?  Yes  No
 
Step 6. Special Instruction Step 5. Special Instruction
 
 
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