Date Order : *   Date Required : *
Delivery Address: *   Hearing Clinic : *
Client Name:  *   Patient reference:
Contact Email: *   Contact Phone:  *
 
 
Step 1. Audiogram
Hz 250 500 1000 2000 4000
LEFT AC (dB HL) dBHL
RIGHT AC (dB HL) dBHL
 
Step 2. Choose hearing instrument
 
Sky M-M    Sky M-PR    Sky M-SP 
 
Model R L
Sky M90-M
Sky M70-M
Sky M50-M
Sky M30-M
 
Step 3. Choose your Sound Delivery System
 
  Tone Hook with Earmould
  Ear mould
  Vent
  SlimTube with domes or SlimTip
  Acoustic coupling
  Tube Length
  Housing Color
  Ear Hook
 
Step 4. Choose accessories
 
TV Connector RemoteControl PartnerMicâ„¢
 
Step 5. Customer Preference Service
 
In case of space constraint, please give Performance/functions priority.
Please contact me for approval of any changes.
 
Step 6. Pediatric Kit
 
Do you require a pediatric kit?  Yes  No
 
Step 7. Special Instruction
 
 
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