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 Quest 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
RIC R L
Custom R L
BTE R L
RIC R L
Custom R L
BTE R L
RIC R L
Bolero Q90
Vitro Q90
Naida Q90 RIC
Naida Q90
Audeo Q90
CROS
Sky Q90
Sky Q90 RIC
Bolero Q70
Vitro Q70
Naida Q70 RIC
Naida Q70
Audeo Q70
Sky Q70
Sky Q70 RIC
Bolero Q50
Vitro Q50
Naida Q50 RIC
Naida Q50
Audeo Q50
Sky Q50
Sky Q50 RIC
Bolero Q30
Vitro Q30
Naida Q30 RIC
Naida Q30
Audeo Q30
CROS
CROS
Baseo Q15*
Tao Q15

*- Only available from Jan. 2015

2.c Please choose the below options
  Options Right Ear Left Ear
  Models
--select--
--select--
  Type (For CROS only)
  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
  Venting
  Wax Management - SmartGuard recommended (Select 2nd choice if canal deemed too small to have SmartGuard)
  Wax Management
  Handling Option
  Options Right Ear Left Ear
  Models
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
  Type (For CROS only)
Step 3. Choose your Wireless Solutions
 
PilotOne ComPilot TVLink/S TV Link S/ComPilot
Note: Wireless accessory is not compatible with CIC , Audeo Q-10, Tao and Baseo Q
 
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 5. Pediatric Kit
 
Do you require a pediatric kit?  Yes  No
 
Step 6. Special Instruction
 
 
Enter Security Code
 
Security Image
Can't read the image? click here to refresh.