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
mini IX      
V      
III      
yes IX
V
III
smart IX
V
III
 
Receiver L R
xStandard Receiver Length
xPower Receiver Length
Dome Type
Custom Shells
Vent Options
Special Instructions  
 
 
 
CRT Components Overview (xReceiver+)   Compatibility
xReceiver +   Generic Parts   xReceiver +
  Standard Power
standerd power
lenght Left Right Left Right
0 054-0465 054-0461 054-0473 054-0469
1 054-0466 054-0462 054-0474 054-0470
2 054-0467 054-0463 054-0475 054-0471
3 054-0468 054-0464 054-0476 054-0472
 
generic plane   generic plane
026-0697   002-0191
  generic plane  
  002-0404-1  
generic plane   generic plane
098-0282   004-0628-001
 
  Standard Power
Domes LeftRight LeftRight
Open x x
Closed x x
Power x  
Custom Shell    
SlimTip x  
cShell x x
xShell   x
         
Domes   xShell    
Open Short Open Long Closed Power
open short open long closed power
5S 054-0042 5S 054-0045 S 054-0048 9 054-0050
7S 054-0043 7S 054-0046 L 054-0049 10 054-0051
10S 054-0044 10S 054-0047   11 054-0052
 
Custom Shells
SlimTip cShell xShell
open short open long closed
 
generic plane   generic plane
004-2107   004-2095-12
  generic plane  
  003-0386-1  
generic plane   generic plane
004-2796-xxx   004-0250-1
  generic plane  
  004-0937-471  
  phonak