Date Order : *   Delivery Date : *
Contact Name:  *   Hearing Clinic : *
Ordered By: *   Patient Reference:
Contact Email ID:  *   Contact Phone:  *
 
Binoural Order    Monoural Order
 
 
Step 1. Audiogram (required for AOV)
Hz 250 500 1000 2000 4000
Right dBHL
Left dBHL
 
Step 2. Product
 
Virto M-Titanium    Virto M-10 NW O    M-312 NW O    M-312 
 
Model R L
M90
M70
 
Step 3 - Product Options
 
  Options Right Ear Left Ear
  FitGuide Value
  Power Level
  Shell Type
  Vent Size
  Wax system
  User controls
  Shell color
  Faceplate Color
  Push Button
  VC Wheel
  T-Coil
  Removal Line
  Titanium Surface
Note:

1)  IIC : Invisible In Canal
    CIC : Completely In Canal
    MC : Mini Canal
    ITC : In The Canal
    HS : Half Shell
    FS : Full Shell
   

2)  NW = Non Wireless
    O = Omni Directional
    Virto M-312 is Wireless and Directional

   
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. Special Instruction
 
 
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