Resound Earmold Order Form – Fill Out and Use This PDF

It’s time to simplify your process with the Resound Earmold Order Form. Our form is intended to streamline your ordering process and make obtaining custom earmolds easy. We understand that no two ears are the same, so our form allows you to customize your ear impressions and submit orders just minutes. With our form, you can quickly choose the right style of device you need plus enter design options, materials and colors – all within minutes! And best of all – it’s free. Try out the Resound Earmold Order Form today, and experience simplified ordering for yourself!

Resound Earmold Order Form PDF Details

Are you searching for the best way to order custom-fit hearing device earmolds? Look no further – our Resound Earmold Order Form is your one-stop solution! With our easy process, you can quickly and accurately place an order for your ideal earpiece – perfect for both existing patients and new customers alike. Whether you’re a first time user or experienced with these products, we’ve taken every step possible to make this form as simple as possible. In today's blog post, we'll explore how to get started ordering earmolds from Resound. Get ready to take the guesswork out of buying custom-fitted earsets!

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

Resound Earmold Order Form PDF Details

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