Signature RIC / DEAFMETAL® Signature RIC Earmolds & Deafmetal® Order NumberAccount Number*Format: AA12345 Step 1: Patient, Audiologist, and Impression DetailsDateSame Day Lab Process & Overnight ShippingAll "same day" lab requests must be received by 10:30 AM. Otherwise, order will be shipped on next business day. Additional charges of $16/ear Lab Fee and $30 Overnight Shipping apply. Yes Business Name*Promo CodePO# (If applicable)Medicare/Medicaid# (If applicable)Patient Name* First Last Audiologist Name* Au.D.Ph.D.M.A.M.S.Dr.Mr.Mrs.Ms. Prefix First Last Audiologist Email* Audiologist Phone (USA)Audiologist Phone (International)Audiologist PhoneAudiologist Phone: InternationalImpressions (R/L)Left & RightLeftRightIf you are configuring earmolds differently for each ear, please complete two online forms, one for each ear.Use impressions from previous order #Return ImpressionsNo (Default)YesIs this a REMAKE?*NOYES REMAKES: To order an earmold remake, you may upload photos of the earmolds in question.Reason for Remake.Are you mailing your impressions?* YES NO Are you uploading your impression scans? YES What type of scanner did you use?*If you are submitting LANTOS ear scans for this order, please upload scans to the LANTOS Cloud.Otoscan®Impression ScansOtoscan® Package ID NumberUpload Impression Scans Drop files here or Select files Accepted file types: zip, stl, asc, Max. file size: 512 MB. Impression Quality Standard It is important to submit a complete and accurate impression. 1GB upload limit.Upload LANTOS Scans Drop files here or Select files Accepted file types: zip, stl, asc, Max. file size: 512 MB. Impression Quality Standard It is important to submit a complete and accurate impression. 1GB upload limit.Upload In-Ear Scans - All Others Drop files here or Select files Accepted file types: zip, stl, asc, hps, Max. file size: 512 MB. Impression Quality Standard It is important to submit a complete and accurate impression. 1GB upload limit.Do you have any supporting documents or photos? YES Upload Supporting Documents and PhotosSupported file-types: .jpg .png .psd .doc .docx .pdf .xlsx .xls .tif .tiff .txt Drop files here or Select files Accepted file types: jpg, png, psd, doc, docx, pdf, xlsx, xls, tif, tiff, Max. file size: 512 MB. Special Instructions Step 2: Shipping DetailsShip to Office or Patient?*Ship to Main OfficeShip to Satellite OfficeShip to PatientMain Office NameSatellite Office NamePatient Name First Last Ship to Main Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial 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2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Ship to Patient Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Select Shipping Method Ground 2nd Day Air Next Day Air USPS Regular USPS Priority Mail Use Your Own Account (optional) FedEx UPS Your Account NumberYour Account NumberSAME-DAY LAB SHIPPINGYou are submitting a "Same Day Lab" order. This includes Overnight Shipping. [$28]Special Mailing Instructions Step 3: Signature RIC Earmolds CUSTOM RIC PRICING $42.00/per piece • Select a Signature RIC earmold below.• You MUST send receivers to Microsonic Inc. for Signature RIC products. • Please use our HEARING AID EARMOLDS portal to order silicone RIC earmolds that do not require you to mail-in receivers.Signature RIC StylesFor RIC / SLIM (thin) Tube Signature CIC Style for RIC / Slim (thin)Tube Signature CIC Style for RIC / Slim (thin)Tube#Lilly#CV4 CAVERN#CVO4 OPEN CAVERN#CV5 CAVERN-LOK#CVO5 OPEN CAVERN-LOKSignature BTE w/#13 Tubing, Slim (thin) Tube, or RIC#1A REGULAR WITH TUBING#2 SKELETON#2A ¾ SKELETON#2B ½ SKELETON#OF2 OPEN-FIT SKELETON#SL2 SLIM-FIT SKELETON#3 SEMI-SKELETON#4 CANAL#SL4 SLIM-FIT CANAL#OF4 OPEN-FIT CANAL#5 CANAL-LOK#SL5 SLIM-FIT CANAL-LOK#5A CANAL WITH HELIX#5L CANAL WITH LONG LOK#OF5 OPEN-FIT CANAL-LOK#6 SHELL#SL6 SLIM-FIT SHELL#7 CANAL SHELL#7A 3/4 SHELL#OF7 OPEN-FIT CANAL SHELL#SL7 SLIM-FIT CANAL SHELL#17 CROS B#21A - ADVANCED DESIGN FREE FIELD (with SAV)#21B - ADVANCED DESIGN FREE FIELD (with SAV)#21C - ADVANCED DESIGN FREE FIELD (with SAV)#41A - CANAL-LOK ADV. DESIGN FREE FIELD (with SAV)#41B - CANAL-LOK ADV. DESIGN FREE FIELD (with SAV)#41C - CANAL-LOK ADV. DESIGN FREE FIELD (with SAV)Standard Earmolds for RIC / Slim (thin) Tube#OF2 - OPEN-FIT SKELETON (w/IROS) (w/slim tube)#SL2 - SLIM-FIT SKELETON (specify vent size + receiver model)#OF4 - OPEN-FIT CANAL (w/IROS) (w/slim tube)#SL4 - SLIM-FIT CANAL (specify vent size + receiver model)#OF5 - OPEN-FIT CANAL-LOK (w/IROS) (w/slim tube)#SL5 - SLIM-FIT CANAL-LOK (specify vent size + receiver model)#SL6 - SLIM-FIT SHELL#OF7 - OPEN-FIT CANAL-SHELL (w/IROS) (w/slim tube)#SL7 - SLIM-FIT CANAL-SHELL#OF21 - OPEN-FIT ADV DESIGN FREE FIELD (w/SAV) (w/slim tube)Standard Non-Occluding w/#13 Tubing & Slim (thin) Tubes#16 CROS A (no vent)#17 CROS B (no vent)#18 CROS C (no vent)#21A ADV. DESIGN FREE FIELD#21B ADV. DESIGN FREE FIELD#21C ADV. DESIGN FREE FIELD#41A ADV. DESIGN FREE FIELD# 41B ADV. DESIGN FREE FIELD# 41C ADV. DESIGN FREE FIELDOther Custom Earmolds#23 - Solid, non-floating#23A - Solid, non-floating, w/Handles#23B - Solid, non-floating, w/Cord#23C - Solid, non-floating, w/Handles & Cord#24 - Solid, Floating#24A - Solid, Floating, w/Handles#24B - Solid, Floating, w/Cord#24C - Solid, Floating, w/Handles & Cord#26 - Skeleton Uplift#27 - Canal Shell Uplift#30A - Custom Sleeves for Earphones#30C - Custom Tips for Apple AirPods® / AirPods Pro® #BF4 Lilly Features: • Discreet CIC Style • Venting (optional) • RIC Only • Recessed, position at 2nd bend • Built-in Universal Connector for Receiver • Right / Left Engraving is included • Platinum Silicone Material • Translucent with matte • M60 Medical Grade Silicone #CV5 CAVERN-LOK Description • CIC Style, Occluding • RIC or SLIM (Thin) TUBE • Discreet Retention Lock (recommended) • Right / Left Engraving is included • Transparent Tint • M60 Medical Grade Silicone #CV4 CAVERN Description • CIC Style, Occluding • RIC or SLIM (Thin) TUBE • No Retention Lock • Right / Left Engraving is included • Transparent Tint • M60 Medical Grade Silicone #CV05 OPEN CAVERN-LOK • CIC Style, Open-Fit • RIC or SLIM (thin) TUBE • Discreet Retention Lock (recommended) • Right / Left Engraving is included • Transparent Tint • M60 Medical Grade Silicone #CVO4 OPEN CAVERN • CIC Style, Open-Fit • RIC or SLIM (Thin) TUBE • No Retention Lock • Right / Left Engraving is included • Transparent Tint • M60 Medical Grade SiliconeEar SelectionRight / LeftRightLeftVenting OptionsNo Vent (Default)Yes - Small VentYes - Medium VentYes - Large Vent #1A REGULAR W/TUBING • Logo $6.00 • Special Shape $9.50 Special Notes: • Occluding • All Materials EXCEPT M2000 • Used with external receiver that snaps into earmold #2 SKELETON • Logo N/A • Special Shape N/A Special Notes: • Occluding • All Materials • Open space in concha for appearance #2A ¾ SKELETON • Logo N/A • Special Shape N/A Special Notes: • Occluding • All Materials • Recommended Skeleton style for dexterity issues #2B ½ SKELETON • Logo N/A • Special Shape N/A Special Notes: • Occluding • All Materials • Recommended Skeleton style for dexterity issues #OF2 OPEN-FIT SKELETON • RIC & Slim (thin) Tube • Logo N/A • Special Shape N/A#SL2 SLIM-FIT SKELETON • RIC & Slim (thin) Tube • Logo N/A • Special Shape N/A#3 SEMI-SKELETON • Logo N/A • Special Shape N/A Special Notes: • Occluding • All Materials • Recommended for ears with flat concha rim to avoid earmold sticking out from ear#4 CANAL • Logo N/A • Special Shape N/A#SL4 SLIM-FIT CANAL • RIC & Slim (thin) Tube • Logo N/A • Special Shape N/A#OF4 OPEN-FIT CANAL • RIC & Slim (thin) Tube • Logo N/A • Special Shape N/A#5 CANAL-LOK • Logo N/A • Special Shape N/A#SL5 SLIM-FIT CANAL-LOK • RIC & Slim (thin) Tube • Logo N/A • Special Shape N/A#5A CANAL WITH HELIX • Logo N/A • Special Shape N/A#5L CANAL WITH LONG LOK • Logo N/A • Special Shape N/A#OF5 OPEN-FIT CANAL-LOK • RIC & Slim (thin) Tube • Logo N/A • Special Shape N/A#6 SHELL • Logo $6.00 • Special Shape $9.50#SL6 SLIM-FIT SHELL • RIC & Slim (thin) Tube • Logo $6.00 • Special Shape $9.50#7 CANAL SHELL • Logo N/A • Special Shape N/A#7A 3/4 SHELL • Logo $6.00 • Special Shape $9.50#OF7 OPEN-FIT CANAL SHELL • RIC & Slim (thin) Tube • Logo N/A • Special Shape N/A#SL7 SLIM-FIT CANAL SHEL • RIC & Slim (thin) Tube • Logo N/A • Special Shape N/A#17 CROS B • Logo N/A • Special Shape N/A#21A ADV. DESIGN FREE FIELD • S.A.V. included • Logo N/A • Special Shape N/A#21B ADV. DESIGN FREE FIELD • S.A.V. included • Logo N/A • Special Shape N/A#21C ADV. DESIGN FREE FIELD • S.A.V. included • Logo N/A • Special Shape N/A#41A ADV. DESIGN FREE FIELD • CANAL-LOK Style • Logo N/A • Special Shape N/A#41B ADV. DESIGN FREE FIELD • CANAL-LOK Style • Logo N/A • Special Shape N/A#41C ADV. DESIGN FREE FIELD • CANAL-LOK Style • Logo N/A • Special Shape N/A#OF2 OPEN-FIT SKELETON • Provides largest vent possible.#SL2 SLIM-FIT SKELETON • S.A.V. + $3.00 #OF4 OPEN-FIT CANAL • Provides largest vent possible • L/R Indicators included • Acrylic + $1.00#SL4 SLIM-FIT CANAL • L/R Indicators included • Acrylic + $1.00 • S.A.V. + $3.00#SL5 SLIM-FIT CANAL-LOK • S.A.V. + $3.00#OF5 OPEN-FIT CANAL • Provides largest vent possible.#SL6 SLIM-FIT SHELL • S.A.V. + $3.00#OF7 OPEN-FIT | CANAL-SHELL • Provides largest vent possible.#SL7 SLIM-FIT CANAL-SHELL • Provides largest vent possible.#16 CROS A (no vent) • Arylic Only - $42.00 • Completely open canal • Designed for CROS & many IROS fittings • Canal-Long Lok Style.#17 CROS B (no vent) • Designed for CROS and many IROS fittings • Skeleton style#18 CROS C (no vent) • Recommended for attaching the offside microphone or transmitter in a BTE CROS or BICROS fitting#18 CROS C (no vent) • Seals entrance while leaving the entire canal unoccluded. • Eliminates feedback • SAV included#21B ADV. DESIGN FREE FIELD • Seals entrance while leaving the most canal unoccluded. • Eliminates feedback • SAV included#21C ADV. DESIGN FREE FIELD • A step reduction at the end of the canal for moderate occlusion • Eliminates feedback • SAV included#41A ADV. DESIGN FREE FIELD • CANAL-LOK STYLE • Functions identical to #21A#41B ADV. DESIGN FREE FIELD • CANAL-LOK STYLE • Functions identical to #21B#41C ADV. DESIGN FREE FIELD • CANAL-LOK STYLE • Functions identical to #21C#23 - Solid, Non-Floating • Full Shell Style • Glossy Finish • M35 Silicone [Translucent Colors]#23A - Solid, Non-Floating w/Handles • Full Shell Style • Glossy Finish • M35 Silicone [Translucent Colors]#23B - Solid, Non-Floating w/Cord • Full Shell Style • Glossy Finish • M35 Silicone [Translucent Colors]#23C - Solid, Non-Floating w/Cord • Full Shell Style • Glossy Finish • M35 Silicone [Translucent Colors]#24 - Solid, Floating • Full Shell Style • Glossy Finish • M35 Silicone [Translucent Colors]#24A - Solid, Floating w/Handles • Full Shell Style • Glossy Finish • M35 Silicone [Translucent Colors]#24B - Solid, Floating w/Cord • Full Shell Style • Glossy Finish • M35 Silicone [Translucent Colors]#24C - Solid, Floating w/Handels + Cord • Full Shell Style • Glossy Finish • M35 Silicone [Translucent Colors]#26 - Skeleton Uplift • Full Shell Style • Glossy Finish • M35 Silicone [Translucent Colors]#27 - Canal Shell Uplift • Full Shell Style • Glossy Finish • M35 Silicone [Translucent Colors]#30C - Earmold for AirPods Pro® • Skeleton Style • Compatible with Apple® products • Apple® Models: EarPods®, AirPods®, AirPods Pro® • Glossy Finish • M35 Silicone [Translucent Colors]#30A - Earmolds for Earphones • Canal Style • Compatible with most earphones • Default Style for Sennheiser® earphones • Sennheiser® Models: 80S, 80S BT, 800S • Glossy or Matte Finish • M35 Silicone [Translucent Colors]Have you selected a RIC earmold?* Yes - I have selected a RIC Earmold. Step 4: DEAFMETAL® JewelryHearing Aid JewelryDEAFMETAL® Products Yes - I would like to BUNDLE my RIC with DEAFMETAL® jewelry! DEAFMETAL® Products Purchase DEAFMETAL® jewelry only. BUNDLE Your RIC Order with DEAFMETAL® jewelry! Clear Selection DEAFMETAL® is an award-winning jewelry innovation for hearing aids which transforms hearing devices into personalized jewelry. Personalized designs significantly improve the self-image and self-confidence of hearing aid users. • Deafmetal® aims to improve the lifestyle of hard of hearing people by augmenting an individual’s personal style. • Deafmetal® designs hearing aid jewelry for women, men, and children. • All Deafmetal® jewelry is sold as single pieces, not in pairs. • Deafmetal® Holsters are sold separately.Special Bundle Pricing!Microsonic's Au.D. Special Pricing • 1 Custom RIC Earmold• 1 DEAFMETAL® Jewelry Piece • 1 DEAFMETAL Holsterd $59.00Your Promo Code Has Been AppliedOffer Valid Through July 1st, 2021MICROMETALTo order additional pieces of DEAFMETAL® jewelry at Audiologist Pricing, please visit our AuD Accessory Store.Please select a DEAFMETAL® product below by clicking on a picture. Hearing Aid Jewelry DM HolsterIncluded Free Lonley Feather$22.80 Silver Rose$25.20 Shooting Star$22.80 Wings$17.40 Z-Heart$25.20 Vine$25.20 Silver Star$22.80 Sienna Gold$25.20 Riley Stars$22.80 Half Hoop$17.40 Hope 1$22.80 DM Statement$25.20 Butterflies$17.40 Bolt$22.80 Bling Bliss$22.80 Clear Selection QuantitySpecify amount. * Bundle Pricing includes 1 jewelry piece.12345678910 Special Instructions Step 5: Rate Your Experience(Optional)Your online ordering experience.Very PoorPoorFairGoodExcellentMicrosonic's product quality.Very PoorPoorFairGoodExcellentMicrosonic's customer service.Very PoorPoorFairGoodExcellentAny comments or suggestions? {all_fields}
