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 Venture Hearing 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
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 V90
Virto V 90
Audeo V90
Naida V90
Phonak Cros II-312
Naida V90
Sky V90
Sky V90
Bolero V70
Virto V 70
Audeo V70
Naida V70
Phonak Cros II-13
Naida V70
Sky V70
Sky V70
Bolero V50
Virto V 50
Audeo V50
Naida V50
Naida V50
Sky V50
Sky V50
Bolero V30
Virto V 30
Audeo V30
Naida V30
Naida V30
Sky V30
Sky V30
Cros II 312
Cros II 312
Cros II 13
Cros II 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
  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
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
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.d If you have chosen CRT Products please choose the below options
  Options Right Ear Left Ear
  Receiver
  Earpiece
  Venting
  Receiver Wire length
  Housing Color

*xUP is not available for Audio V10 model.

Step 3. Choose your Wireless Solutions
 
PilotOne II EasyCall II DECT Phone II ComPilot Air II
ComPilot II TV Link II ComPilot + TV Link II Bundle
 
Step 4. 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
 
Do you require a pediatric kit?  Yes  No
 
Step 6. Special Instruction
 
 
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