Download - 2103 GS RIC LT MFi OrderForm MK605350 rC 508
*UP receiver only available in Encased earmolds
4a RESOUND STANDARDRIC RECEIVERS AND DOMES
RIC Receiver
tube length
Size L R
0
1
2
3
4
For proper fit, measure from the top of the ear to the top of the ear canal using the ReSound measuring tool.
Rechargeable Mini RIC
Zinc Air Mini RIC
Zinc Air RIC
2.4 GHz wireless L R L R L R
ReSound ONE™Charger included in order of RT961-DRWC
RT961-DRWC RT961-DRW RT962-DRW
Battery Lithium-ionrechargeable #312 #13
Program selector Programmable Push button
Programmable Push button
Multifunction Switch
Volume control Programmable Push button
Programmable Push button
Multifunction Switch
RIC receivers (power level)M&RIE � � � � � � � � � � � � � � � � � � � �
Low power (LP) � � � � � � � � � � � �
Medium power (MP) � � � � � � �
High power (HP) � � � � � � � � � �
Ultra power (UP)* � � � � � � � � �Color (keychain color)
Gold (70) � � � � � � � � � � � � � � � � �Warm Grey (71) � � � � � � � � � � �Espresso (72) � � � � � � � � � � � � �Deep Black (73) � � � � � � � � � � �
Bronze (74) � � � � � � � � � � � � � � �
Champagne (75) � � � � � � � � � � �
Sparkling Silver (76) � � � � � � �
Graphite (77) � � � � � � � � � � � � �
3 MODEL AND OPTIONS
POW
ERST
DCL
OSE
D
Domes Size L R
Large Medium
Small Tulip
Large Medium
Small
Large Medium
Small
4bCUSTOM RIC EARMOLD OPTIONS
OR
GOVERNMENT SERVICES ORDER FORM
RESOUND ONE1.800.392.9932 FAX 1.888.768.1867
RACHAP
ACTIVE DUTY INDIAN HEALTH
TRICARE
COMMUNITY CARE PROVIDER
BILL TO Acc’t #:
•• Office:
Address:
Address:
City/State:
Zip: P.O.
SHIP TO Acc’t #:
Date: Phone:
Contact name:
Email:
•• Facility:
Address:
Address:
City/State:
Zip:
2 SPECIAL INSTRUCTIONS
(PLEASE PRINT CLEARLY)
Patient name: SSN:
LAST:
FIRST:
Previous user: YES NO
Audiogram data:
Left air:
Bone:
LDL:
Right air:
Bone:
LDL:
1 PATIENT DATA
250 500 750 1k 1�5k 2k 3k 4k 6k 8k
AVAILABLE DEFAULT
SHELL COLORClear � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Light � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Beige � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Medium � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Dark � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Rose (n/a for Encased) � � � � � � � � � � � � � � � � � � � � � � � � � � � � �EarLusion Light (n/a for Encased)� � � � � � � � � � � � � � � � � � � Espresso (hard only) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Red/Blue (default is Red for right, Blue for left) � � � � � � � �
FACEPLATE COLOR (Encased only)Light � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Beige � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Medium � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Dark � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Espresso � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Anthracite � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Clear � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �
CANAL LENGTHFactory select � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �As marked � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �
VENTINGFactory select � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �MOV (vent modification recommended) � � � � � � � � � � � � � � � � � � �SAV � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Pressure� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �None � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �
VENT MODIFICATIONSemi-IROS � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �IROS � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �
WAX PROTECTION (Encased and hard only)HF3 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �GN Wax Filter (default for Encased) � � � � � � � � � � � � � � � � � � � � �None (default for hard) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �
OPTIONSRemoval cord � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Blue/Red dots � � � � � � � � � � � � � � � � � � � � � � � Size (check):
Patient initials � � � � � � � � � � � � � � � � � � � � � � �
RETENTIONCanal Lock (n/a for Skeleton) � � � � � � � � � � � � � � � � � � � � � � � � �Helix Lock (n/a for Skeleton) � � � � � � � � � � � � � � � � � � � � � � � � � �Skeleton Lock (n/a for Skeleton) � � � � � � � � � � � � � � � � � � � � � �Semi-Skeleton Lock (n/a for Skeleton) � � � � � � � � � � � � � � � � �
PLEASE SEND Air bills Impression mailers
L
L R
MK605350 REV C 2021.03
5 RESOUND WIRELESS ACCESSORIES
($) ReSound Remote Control
($) ReSound Remote Control 2
($) ReSound TV Streamer 2
($) ReSound Phone Clip+
($) ReSound Multi Mic
($) ReSound Micro Mic
($) Additional charge for wireless accessories
ENCASED (n/a for M&RIE)
MICROMOLD
SKELETON
TRUFIT™ IMPRESSION—THE 16/4 RULETake an OPEN JAW impression when:• Ear geometry lacks retention• Patient has severe TMJ movement• Instrument migrates out of ear• Instrument is loose or has feedback
Full helix4mm
16mm
MATERIAL
Hard (acrylic) Soft (silicone)
(n/a for Encased)
L
L
L
R
R
R
L
LLL
R
RRR
L
LL
R
RR
LLLLL
RRRRR
LLLLLLL
RRRRRRR
L
L
L
L
LLLLLLLL
R
R
R
R
R
RRRRRRRR
AVA
ILA
BLE
D
EFA
ULT
SMALL LARGEor
6 EARMOLDS