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
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
  Removal Line
  Titanium Surface

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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