Date Order : *   Date Required : *
PO/Indent No :   Hearing Clinic :
Client Name:   Client ID :
Age :   
Ordered By : *   Contact Phone : *
Contact Email ID :  *
 
 
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 SPICE Hearing Instrument Models (Style, Product Family, Options)
 
2.a Choose the Style you like to Order
 
microBTE/M H2O    BTE    Custom    CRT 
 
Please use separate Phonak CROS order form to order your Phonak CROS transmitter)
2.b Choose which Product Family you want to order
BTE/Custom R L
CRT Wireless R L
CRT Non-Wireless R L
R L
R L
Audéo S SMART IX
Phonak Ambra
Ambra nano
Ambra M H2O
Audéo S MINI IX
Naída S IX UP
Naida S CRT IX
Naída S IX SP
Audéo S SMART V
Phonak Solana
Solana nano
Solana M H2O
Audéo S MINI V
Naída S V UP
Nios S H2O V
Naida S CRT V
Naída S V SP
Audéo S SMART III
Phonak Cassia
Cassia M H2O
Cassia nano
Audéo S MINI III
Naída S III UP
Nios S H2O III
Naida S CRT III
Naída S III SP
Phonak Dalia
Dalia M H2O
Naída S I UP
Naída S I SP
Audéo S SMART I
   
2.c If you have chosen microBTE/BTE, please choose the below options
  Options Right Ear Left Ear
  Models/Power Levels (2ccGain/MPO)
  Standard Tube Options
  Ear mould
  Vent
  Slim Tube Options
  Earpiece
  Tube Length
  Housing Color
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 ? AOV recommended
  Venting
  Wax Management - SmartGuard recommended (Select 2nd choice if canal deemed too small to have SmartGuard)
  Wax Management
  Handling Option
All ITC & FS comes with Standard Volume Control (VC), Program Button (PB), Telecoil (TC), Remote Coil (RC) & EasyPhone (EP).
Remote Coil (RC) is optional for CIC and is possible if size permits. Should you wish to not have any of these options- please specify below.
2.e If you have chosen CRT Products please choose the below options
  Options Right Ear Left Ear
  Receiver
  Earpiece
  Venting
  Receiver Wire length
  Housing Color
Step 3. Choose your Wireless Solutions
 
PilotOne myPilot ComPilot TVLink/S TV Link S/ComPilot
 
Step 4. Customer Preference Service
 
Tick if substitutions for technical reasons are acceptable without approval
Call for approval if changes are required
In case of space problems, please give size priority
In case of space problems, please give options priority
 
Step 6. Special Instruction
 
 
Enter Security Code
 
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