Resound Earmold Order Form – Fill Out and Use This PDF

The Resound Earmold Order Form is an essential document designed for the precise ordering of custom earmolds, catering especially to government services. This comprehensive form encompasses various sections such as billing and shipping information, patient data including audiogram details, and specific requirements for mold type, materials, and additional options. To ensure a smooth and efficient order process, please fill out the form thoroughly by clicking the button below.

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Resound Earmold Order Form PDF Details

In the realm of audiological support and services, the Resound Earmold Order Form plays a crucial role, especially within government services. Designed to streamline the process of ordering custom-made earmolds, this form facilitates the precise customization needed to accommodate individual hearing needs. It incorporates sections for billing and shipping information, ensuring that the earmolds reach the correct location without delay. The form also gathers comprehensive patient data, including age, social security number, and audiogram data, to tailor the earmold to the patient's specific hearing requirements. Special instructions can be added, allowing for further customization. A diverse range of models and style options, including variations in venting, material (either acrylic or silicone), and additional features like color and wax protection, are available to choose from, ensuring that every patient receives an earmold that fits their needs and lifestyle. Moreover, it includes options for earmold styles and tube types, addressing different types of hearing aids and levels of hearing loss. This form demonstrates a meticulous approach to patient care, highlighting the importance of accuracy and customization in the creation of earmolds, thereby significantly contributing to the wearer's auditory experience and quality of life.

Question	Answer
Form Name	Resound Earmold Order Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	resound order forms, resound earmold order form, resound service form, resound forms

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GOVERNMENT

SERVICES

EARMOLD ORDER FORM

1-800-392-9932 FAX 952-852-1990

BILL TO AccÕt #:

Office:______________________________________________

Address:______________________________________________

City/State: ____________________________________________
Zip:___________________		P.O.

SHIP TO	AccÕt #:

Date:________________		Phone: ________________________
Contact name: _______________________________________
Email: ______________________________________________

Facility:_____________________________________________
Address:______________________________________________
	RACHAP	!
Address:	ACTIVE DUTY	!

INDIAN HEALTH !

City/State: ____________________________________________

OTHER !

Zip:___________________

1 PATIENT DATA:

Patient’s name:	SSN:
LAST:
FIRST:

Patient’s age: Previous user: ! YES ! NO

Audiogram data:

250

500

1.5k

Left air:

Right air:

ATTACH COPY OF AUDIOGRAM, OR FILL IN ABOVE

2 SPECIAL INSTRUCTIONS:

!CHANGES MAY BE MADE WITHOUT CALLING

Other instructions: __________________________________

EM	EM2	EM3	EM4	EM5	EM6 / EM7	EM8	EM9

3 MODEL	FLEX-VENT	CANAL	HALF SHELL	FULL SHELL	CANAL LOCK	! SKELETON	SKELETON	RIE (RIC)
	(OPEN)					! SEMI SKELETON	(OPEN)	MICRO-MOLD

TYPE	hard soft	hard soft	hard soft hard soft	hard soft hard soft hard soft hard soft
	L R L R L R L R L R L R L R L R L R L R L R L R L R L R L R L R

hard = acrylic	! ! ! !	! ! ! !	! ! ! ! ! ! ! !	! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !
soft = silicone

Write in BTE/RIE model or
receiver size to be ﬁtted:		________	________	________	________	________	________	________	________
… with OPTIONS:		________	________	________	________	________	________	________	________
… with OPTIONS:
Color
Clear		! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !
EarLlusion light		! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !
EarLlusion medium		! !	! !	! !	! !	! !	! !	! !	! !
EarLlusion dark		! !	! !	! !	! !	! !	! !	! !	! !
Vent type
Factory select†		! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !		! ! ! !
MOV (no SAV)		! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !		! ! ! !
SAV (largest possible)		! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !		! ! ! !
Pressure			! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !		! ! ! !
None			! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	std std std std	! ! ! !
IROS			! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !		! ! ! !
Semi-IROS			! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !		! ! ! !
Other
Canal length
Factory select†	Clear Pink Lt brown	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !		! ! ! !
As marked		! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !		! ! ! !
Tube type
13 Standard	! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !
13 Thick1	! ! !		! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !
Slim tube	std	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !
Other		! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !
Tube retention
Glue!			! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !
Friction Þt (not glued)		! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !
Tube lock		! !	! !	! !	! !	! !	! !	! !
Wax protection
None		! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !
HF3		! !	! !	! !	! !	! !	! !		! !
CeruSTOPª		! !	! !	! !	! !	! !	! !		! !
Other
Removal cord		std std std std	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !		std std std std	Rev.B
Blue/Red dots		! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	Rev.B
Patient initials		! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	! ! ! !	MK602378
† FACTORY SELECT: LAB CHOOSES MOST APPROPRIATE OPTION (BASED UPON STYLE SELECTION AND AUDIOGRAM DATA)										MK602378

1 13 THICK TUBING IS RECOMMENDED AND IS THE DEFAULT FOR ALL POWER DEVICES							Special options may be accommodated
	!	AVAILABLE	!	DEFAULT	std	STANDARD

							upon request—see Earmold Styles Guide

___________________________________________________

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Step number 1 of completing resound custom ear mold order form

2. The third part is to submit the following blank fields: Address, RACHAP, Address, ACTIVE DUTY, CityState, INDIAN HEALTH, Zip, OTHER, PATIENT DATA, Patients name, SSN, LAST, FIRST, Patients age, and Previous user YES NO.

resound custom ear mold order form writing process described (stage 2)

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Resound Earmold Order Form – Fill Out and Use This PDF

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