Starkey MED-EL Custom Order Form

Patient and Billing/Shipping Information

Patient Details

Patient Last Name: [ ]

First Name: [ ]

Date: [ ]

Billing Information

BILL TO: Account Number: [ ]

Account Name: [ ]

Address: [ ]

Phone: [ ]

Fax: [ ]

Email: [ ]

Contact: [ ]

Shipping Information

SHIP TO: Account Number: [ ]

Account Name: [ ]

Address: [ ]

Phone: [ ]

Email: [ ]

Contact: [ ]

Fax: [ ]

Impression Information

Sending impression with order: [ ] (Print both pages and mail with impression)

Use impression on file: [ ]

SN/SCAN ID: [ ]

SN/SCAN ID: [ ]

Bimodal Hearing Solution Selection

Select options for bimodal hearing solution (left or right) ?️

Step 1: Select Technology Level

Technology

• [ ] L R 24
• [ ] L R 20
• [ ] L R 16
• [ ] L R 12 (Genesis AI only)

Step 3: Select Color

Faceplate Colors

• [ ] L R Pink
• [ ] L R Light Brown
• [ ] L R Medium Brown
• [ ] L R Chestnut
• [ ] L R Dark Brown
• [ ] L R Black

Step 2: Select Custom Product & Matrix

Custom Models

• [ ] L R Edge AI ITE R (IN-THE-EAR RECHARGEABLE)
• [ ] L R Edge AI HS R (HALF-SHELL RECHARGEABLE)
• [ ] L R Edge AI ITC R (IN-THE-CANAL RECHARGEABLE)
• [ ] L R Edge AI CIC (COMPLETELY-IN-CANAL)
• [ ] L R Genesis AI ITE R (IN-THE-EAR RECHARGEABLE)
• [ ] L R Genesis AI HS R (HALF-SHELL RECHARGEABLE)
• [ ] L R Genesis AI ITC R (IN-THE-CANAL RECHARGEABLE)
• [ ] L R Genesis AI CIC (COMPLETELY-IN-CANAL)

Matrix

• [ ] L R L1 (110/40)
• [ ] L R M (115/50)
• [ ] L R P (120/60)
• [ ] L R UP- (123/65)
• [ ] L R UP (130/70)

1 L Matrix not available on ITE R

Shell Colors

• [ ] L R Clear
• [ ] L R Pink
• [ ] L R Light Brown
• [ ] L R Medium Brown
• [ ] L R Dark Brown
• [ ] L R Black
• [ ] L R Red/Blue Shell

Step 3: Select Custom Options

Options

• [ ] Directional²
• [ ] Induction Coil²,³
• [ ] Push-button
• [ ] Digital Volume Control²
• [ ] Tall Volume Control²

Wax Prevention & Shell Options

• [ ] Hear Clear (Default)
• [ ] Wax Cap
• [ ] Extended Receiver Tube
• [ ] Helix Lock
• [ ] Canal Lock⁴
• [ ] Hypoallergenic Coating
• [ ] Canal Bell
• [ ] Removal Handle
• [ ] Removal Notch⁷

Venting Options

• [ ] Manufacturer Select***
• [ ] No Vent
• [ ] Small Vent (0.5mm - 1.8mm)
• [ ] Medium Vent (1.9mm - 2.6mm)
• [ ] Large Vent (2.7mm and larger)
• [ ] Open/BAV (as large as canal allows)
• [ ] Select-A-Vent

***DEFAULT - SELECTS THE OPTIMAL COMBINATION OF RECEIVER AND VENT BASED OFF OF HEARING LOSS, PATIENT HISTORY AND SIZE AND SHAPE OF THE EAR.

² Not available with CIC

³ Not available on ITC/HS R

⁴ Not available on ITE R or HS R

Step 4: Select Charger

Chargers

• [ ] StarLink Premium Charger 2.0
• [ ] StarLink Standard Charger 2.0

Step 5: Select Accessories

Edge AI Wireless Accessories

• [ ] StarLink Remote Control 2.0
• [ ] StarLink Edge Remote Microphone
• [ ] StarLink Edge TV Streamer
• [ ] StarLink Edge Table Microphone

Genesis AI Wireless Accessories

• [ ] StarLink Remote Control 2.0
• [ ] StarLink Remote Mic +
• [ ] StarLink Mini Remote Mic
• [ ] StarLink TV Streamer
• [ ] StarLink Table Microphone

Optional: BTE Earmold for Audio Processor

Earmold Styles

• [ ] L R Canal²
• [ ] L R Hollow Canal¹
• [ ] L R Lock¹
• [ ] L R Canal Lock²
• [ ] L R Half Shell²
• [ ] L R Skeleton²
• [ ] L R Full Shell²

Material

• [ ] L R Digital SLS
• [ ] L R Silicone
• [ ] L R Silicone Printed Tube³

Color

• [ ] L R Clear
• [ ] L R Pink/Flesh Transparent
• [ ] L R Blue⁴
• [ ] L R Tan⁵
• [ ] L R Light Brown/Transparent
• [ ] L R Medium Brown
• [ ] L R Dark Brown

¹ Hollow molds only available in Digital SLS

² Available in Silicone Printed Tube

³ Only available in 13 Extra Heavy Tubing

⁴ Not available in Silicone Printed Tubing

⁵ Only available in Digital SLS

Vent

• [ ] L R IROS
• [ ] L R As Large as Possible
• [ ] L R Select-a-Vent - 3.37 mm
• [ ] L R Large Vent - 2.55 mm
• [ ] L R Medium Vent - 1.6 mm
• [ ] L R Small Vent - 1.2 mm
• [ ] L R Pressure Vent - 0.8 mm
• [ ] L R No Vent

Modifications

• [ ] Bell Canal
• [ ] Canal Length: Short
• [ ] Canal Length: Medium
• [ ] Canal Length: Long
• [ ] Removal String
• [ ] Surface Nanoshield Coating

Step 6: Audiometric Data

Audiometric Information

Special Instructions

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