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
 
 
Product Model R L myPilot
 iCom
 ClicknTalk
 KeyPilot 2
Exelia Art
Versáta
Certéna
FS P VZ/dAZ
ITC/HS VZ/dAZ
ITC/HS P VZ
CIC Petite        
CIC Power Petite        
Milo Plus
FS dAZ        
ITC/HS dAZ        
CIC        
 
Vent Option L R
AOV
No Vent
Pressure (1.0mm)
small (1.5mm)
Medium (2.0mm)
Large (2.5mm)
Open
Wax Prevention L R
Smart Guard (Standard) , (Not for FS power ITE)
HF3 Wax Guard
Cerustop Wax Guard
Shell/Faceplate option L R
Removal Handle
Raised Volume Control
 
 
Special Instructions  
phonak