1

1

HiRes™ Ultra Implant with HiFocus™ Mid-Scala Electrode (CI-1600-04)

HiRes 90K™ Advantage Implant with HiFocus Mid-Scala Electrode (CI-1500-04)

HiRes 90K Advantage Implant with HiFocus™ 1j Electrode (CI-1500-01)

2

4

53

ORDER FORM FOR ADVANCED BIONICS COCHLEAR IMPLANT SYSTEM

Processor Selection and Details

Implant Selection and Details

Naída CI Options

Single Naída CI (303-M374) Dual Naída CI (303-M375) Naída CI + Neptune (303-M381)

If ordering the HiFocus Mid-Scala Electrode, do you need an Insertion Tool? (CI-4207)

YES NO

• Naída CI Sound Processor(includes mic covers, small and large earhooks)

• 2 T-Mic 2 Microphones• 2 Rechargeable Batteries• Naída CI PowerCel™ Charger (with power supply)

• Naída CI Carrying Case• 2 Headpieces• 2 Naída CI UHP Cable (3.5”)

• AB Backpack • Drying Kit

STANDARD COMPONENTS:

Naída CI Color (Select Naída CI System Color): Velvet Black–P8 Sand Beige–P1 Chestnut–P4

Silver Gray–P6 Alpine White–XN Petrol–Q1

Princess Pink–XP* Ruby–P9 Caribbean Pirate–Q3*

Headpiece Color Covers, Cables and Batteries are matched to the Sound Processor Color.

* These colors are not available for the Phonak Naída Link or CROS

1

1. Processor

2. Battery

3. T-Mic™ 2 Microphone

4. Naída CI UHP Cable

5. Headpiece

PowerCel 110 Mini PowerCel 170 Mini PowerCel 230 PowerCel 170 Zinc Air Battery Pak

Naída CI Battery Size (select a total quantity of 2):PowerCel™ 110 Mini (small) PowerCel™ 170

PowerCel™ 170 Mini (standard)

PowerCel™ 230 (extra power)

2

Quantity PowerCelQuantity PowerCelQuantity

Quantity

Quantity

Naída CI T-Mic 2 Microphone Size:Small (pediatric) Medium (standard) Large

Naída CI UHP Cable Length:3.5 inch cables come standard

Substitute with 4.25 inch cables (only if needed)

3

4

(small) (standard)(standardfor Roger)

(for use with 2 Zn-Air

batteries)

(extra power)

Recipient Information

Name:

Guardian (if under 18):

DOB: Phone:

Surgeon: Surgery Date:

Implant Ship Address:

Audiologist: Estimated Activation Date:

Processor Ship Address:

Clinic Name:

Clinic Phone:

Address: Email:

Available on page 2

(standard for Roger)

Compatible with the AquaCase Accessory

2

If selecting this option, 1 UHP and 1 AquaMic will be included in the kit instead of the default 2 UHPs. The AquaCase™ enclosure is compatible with PowerCel 110 mini and PowerCel 170 mini batteries.

For Pediatrics Age 12 and Under:

Melody or Buddy

Listening Check™ with Earbuds

For All:

Zn-Air Battery Pak (includes 1 card of 6 Zn-Air batteries) or

Off-ear wearing clip (includes 11” cable)

Left or Right

Active Lifestyle Kit for Naída CI (select cable length and color)Includes AquaCase with clip, 2 AquaCables.

Wireless Connectivity Options

Phonak Roger™ 17 Receiver (For Naida CI)**Roger 17 requires a PowerCel 170 battery

Phonak ComPilot

Phonak Remote Mic (requires ComPilot)

Phonak TV Link (requires ComPilot)

Phonak DECT Phone

Phonak EasyCall

Additional System Options

AquaMic™ Headpiece (includes Color Covers)

Universal Headpiece (UHP) (includes Color Covers)

2 AquaCables (select color and length)

2 Naída CI UHP Cables (select color and length)

Phonak Naída™ Link CROS (select slimtube side and size)

Color matching same as described above for Phonak Naida Link UP and RIC

Phonak Roger™ Pen* (Transmitter)

Phonak Roger™ Clip-On Mic* (Transmitter)*One transmitter allowed per order form.

Phonak Roger™ 15 Receiver (For Naida Link RIC)

Phonak Roger™ 10 Receiver (for Naida Link UP)

Phonak Roger™ X (for ComPilot and Neptune)

AAA Battery Power (includes adaptor, cable and AAA power pack)

Beige 3.5” 4.25” 11”

Black 3.5” 4.25” 11”

Brown 3.5” 4.25” 11”

White 3.5” 4.25” 11”

Grey 3.5” 4.25” 11”

5 Point Options

2 Point Options

1 Point Options

White 6” 12” 18” 24” 32” 42”

Black 6” 12” 18” 24” 32” 42”

White 6” 12” 18” 24” 32” 42”

Black 6” 12” 18” 24” 32” 42

Headpieces

Lanyard and Armband Small Standard

Spend 5 Points to personalize your cochlear implant system

Phonak Naída Link (Select Model):

Phonak Naída™ Link UP (Ultra Power)

Phonak Naída™ Link RIC (Receiver-in-Canal)

Phonak Naida Link UP and RIC will match system color selected on page 1. Princess Pink and Caribbean Pirate default to an Alpine White Phonak Naida Link. Please inform Customer Service if a different color is desired.Fitting fees not included with the Phonak Naida Link.

If Naída Link RIC, select one of each:Receiver

Power Standard

Side

Left Right

Size

0 1 2 3

Size

0 1 2 3

Black 5” 11” 22” 32”

ORDER FORM FOR ADVANCED BIONICS COCHLEAR IMPLANT SYSTEM

Additional Included Options (if needed)

Additional Power Options (maximum of 2 additional batteries allowed)

PowerCel™ 110 Mini (small) PowerCel™ 170

PowerCel™ 170 Mini (standard)

PowerCel™ 230 (extra power)

Quantity PowerCelQuantity PowerCel Quantity

Quantity

Quantity

(standard for Roger)

Side

Left Right

Recipient Name:

UP RIC

3

Exchange 1 standard UHP with 1 AquamicIncludes color covers. Only check this box if you want an AquaMic™ headpiece

and have not already selected either the Active Lifestyle Kit, or AquaMic and AquaMic Cables, on page 2.

Select Color Covers

White Black Brown Beige

Select color and length of AquaCables

White 6” 12” 18” 24” 32” 42”

Black 6” 12” 18” 24” 32” 42”

Brown 6” 12” 18” 24” 32” 42”

Beige 6” 12” 18” 24” 32” 42”

1

3

2 4

• Neptune™ Sound Processor

• Neptune Connect

• 2 Neptune UHP Cables

• Neptune Clip

• Armband

• Carrying Case

• AAA Batteries (alkaline and rechargeable)

• AAA Battery Charger

STANDARD COMPONENTS:

1. Neptune Processor

2. Neptune Connect

3. Neptune UHP Cable

4. Headpiece

Headpieces Naída + Neptune orders only:

Neptune Color Covers (select one):

Onyx–Ø Sand Castle–30 Alpine White–XN

Petrol–Q1 Princess Pink–XP Ruby–P9

Caribbean Pirate–Q3

1

Neptune Connect (select one):

Black White

2

3

4

Neptune UHP CablesSelect length and color (includes 2)

Beige 6” 12” 18” 24” 32” 42”

Brown 6” 12” 18” 24” 32” 42”

Black 6” 12” 18” 24” 32” 42”

White 6” 12” 18” 24” 32” 42”

ORDER FORM FOR ADVANCED BIONICS COCHLEAR IMPLANT SYSTEM

D000019270©2017 Advanced Bionics AG and affliates. All rights reserved.

Please complete this form and send to the Advanced Bionics Customer Service Department:

Phone: 877.829.0026

Fax: 661.362.1503

Email: CustomerService@AdvancedBionics.com

Recipient Name: