Date Order : *   Required Date : *
Client Name : *      
Age :   NRIC/ FIN No. :
Hearing Clinic :   Email ID : *
Contact Person :   Contact Number : *
 
 

Audiogram (Required for Programming and CIC Power)
  250Hz 500Hz 1kHz 2kHz 3kHz 4kHz 6kHz 8kHz  
Right dBHL
Left dBHL
 
Experienced User :  Yes  No  
 
 Class Type R L myPilot iCom ClicknTalk KeyPilot 2
Exélia Art M
Exélia Art P
Exélia Art SP
Naída IX SP
Naída IX UP
Versáta M
Versáta P
Versáta SP
Nios micro V  
Naída V SP  
Naída V UP  
Certéna M
Certéna P
Certéna SP
Nios micro lll  
Nadia lll SP  
Nadia lll UP  
Milo Plus micro        
Milo Plus SP        
Milo Plus UP        
Milo UP        
Naída l SP        
Naída l UP        
 
 
Ear Mould L R
Full Concha
Half Concha
Canal
Full Concha
Half Concha
Canal
 
Venting L R
No Vent
Pressure (1.0mm)
small (1.5mm)
Medium (2.0mm)
Large (2.5mm)
Open
 
Open Fit Option L R
Slim Tube Size
micro Tube* Size
Dome Type
 
* For Nios micro & Milo Plus microBTE
 
Special Instructions