Serenity Choice Plus Order form

Date: ______ / _______ / _______ PO#: Attention to

DD MM Year _______________________ (at Phonak): ________________________________

Step 1 General Information

Changes can not be made without calling
Ship to Account Number:
Bill to Account Number:
User Name: Last ccccccccccc
Phone#:
Company Name: First ccccccccccc

Address: c Replica of previous earmold — serial #

Contact Name (Audiologist/Dispenser):
Note: Rush orders are not available for custom hearing protection

Step 2 Configuration

FILTER MODEL MATERIAL REMOVAL OPTIONS

c Sleep n.a CU Canal Mold Silicone 108-3045 Removal Handle (Std)

c RF Removal Line Transp.

c Swim KR5 SU Full Shell Silicone 108-3038
c RFE Removal Line Transp. Ext.

c RF Removal Line Transp.

c Comfort KM10 CU Canal Mold Silicone 108-3110
c RFE Removal Line Transp. Ext.

S KI20 Med
c c RF Removal Line Transp.
c Motorsport CU Canal Mold Silicone 108-3106
c KI25 High c RFE Removal Line Transp. Ext.

S KI20 Low
c c RF Removal Line Transp.
S SU Full Shell
c S Silicone 108-3107
c
c Work c KI25 Med
c CU Canal Mold c Acryl 108-3037 c RFE Removal Line Transp. Ext.
c KI30 High

S SU Full Shell
c S Silicone 108-3066
c c RF Removal Line Transp.
c Fly c KM16 Low
c CU Canal Mold c Acryl 108-3044 c RFE Removal Line Transp. Ext.

S KM15 Low
c c RF Removal Line Transp.
S Silicone 108-3067
c
c Music c KM20 Med CU Canal Mold
c Acryl 108-3041 c RFE Removal Line Transp. Ext.
c KM25 High

S SU Full Shell
c S Silicone 108-3109
c c RF Removal Line Transp.
c Shooting & Hunting KIM9
c CU Canal Mold c Acryl 108-3108 c RFE Removal Line Transp. Ext.

027-6646-02/Oct 2021/Serenity Choice Plus Orderform Form #123

S = Standard

Step 3: Choose Material Colour

Acryl Silicone
c 21 Clear transparent c 21 Clear transparent c 17 Green opaque

c 06 Black c 06 Black c 20 Yellow opaque

c 3
7 Blue (Left) c B Blue opaque c 11 Orange opaque
36 Red (Right)
c R Red opaque
Swim & Sleep models are only available in: 34 Light Blue (floatable)

Step 4: Product Options Step 5: Additional Information

c CSB Cord with safety break
*Only available on Acryl Full Shell Molds

Phone: 905-677-1167 or 1-800-876-1167 Fax: 905-677-7536 or 1-800-814-5799