Custom Earmold & Swim Plug Order Form - Prelocked Tubing (TRS)

Oct 5, 2026

Uploaded by Cipher

Custom Earmold & Swim Plug Order Form for Phonak/ Sonova Canada captures patient and claim information, shipping details, and earmold configuration options. The form specifies left/right requirements, earmold areas and ventilation (including Acoustically Optimized Venting with audiogram requirement), ear style selections, and swim plug color and material choices. It also records tube and connector details, including standard prelocked tubing (TRS), available clear/transparent tubing, and tubing variants such as 13M/13T/13D/13W and SlimTube options.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages2

Reading Time5 min

AccessFree to download

STEP 1: General Information

Claim Type and Claim

STEP 2: Order Information

Earmold-only or with BTE instruments

AOV ventilation or Vent Size

STEP 3: Configuration

Venting and ear texture selections

STEP 4: Earmold

Canal mold, canal lock, helix lock, skeleton styles

STEP 5: Materials and Colours

Acrylic and silicone material options

Swim plug colors and lacquer

STEP 6: Tube/Connector Details

Prelocked tubing (TRS) and tube variants

Custom Earmold & Swim Plug Order Form Prelocked Tubing (TRS) Standard for all soft earmolds. Earmold Areas Diagram showing ear areas with names. Ventilation Bore AOV Acoustically Optimized Venting Helix/Cymba Crus First Bend Anti-Tragus Sound Bore Tragus Concha Rim Intertragal Notch Earmold Colours Clear/Transparent (21) Orange (11) Swim Plug Colours Blue (07) 025-0574/Phonak Custom Earmold & Swim Plug Order/Form 27/Jan2023/V14 Sonova Canada | Phone 905-677-1167 or 1-800-876-1167 | Fax 905-677-7536 or 1-800-814-5799 Custom Earmold & Swim Plug Order Form Please note that changes cannot be made without calling. Date: / / PO\#: DD MM Year _______________________ Attention to (at Phonak) : STEP 1: General Information Ship to Account Number: Phone\#: Company Name: Address: SHIP Contact Name (Audiologist/Dispenser): TO First Name: ccccccccccc Last Name: ccccccccccc Age of patient: (Pediatric orders only) Claim Type: m AADL m BCEHP m CNESST m Eastern Health m Greenshield m ISC (NIHB) m Manitoba Health m Nisga’a m ODSP m REGIE m Supp. Health m VAC, DND, RCMP m WCB province m WSIB m Other: Claim \# (Required) : L R | | | | | | | | --- | --- | --- | --- | --- | --- | | | | | | | | 250 500 1K 2K 3K 4K (Please Specify) Please include audiogram with all orders. Audiogram required for Acoustically Optimized Venting (AOV) . | STEP 2: Order Information | | | | | STEP 3: Configuration | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | c A) Please send earmold(s) only | | | | | Venting | | | Ear Texture | | | c B) Please send earmold(s) with BTE hearing instrument(s):
c L Model: Colour:
c R Model: Colour: Please also send me the following accessories: c C) Swim Plugs (Please go to step 5) | | | | | c AOV Acoustically Optimized Vent (Audiogram required)
OR
Vent Size (Customer specified):
c L: mm c R: mm | | | c Soft c Avg. c Firm
Canal Length
Short Med. Long
c L c R cS L cS R c L c R | | | STEP 4: Earmold

Canal Mold c L c R | Style

Canal Lock c L c R |
Helix Lock c L c R |
Semi Skeleton c L c R |
Skeleton c L c R | |
Carved Half Shell c L c R |
Carved Full Shell c L c R | |
Full Shell c L c R | STEP 5: Materials and Colours S = Standard | c Please indicate if Swim Plug is for a Lyric wearer | | Colour | | | | | | | | | | | Lacquer | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Clear
(21) | Rose Tint
(T) | Black
(06) | Orange
(11) | Purple
(08) | Red
(10) | Blue
(07) | Green
(17) | Yellow
(20) | Beige
(26) | Light Blue
(34) | Glossy
Finish | No Lacquer
(Clear only) | | Acrylic Hard (Lucite) | cS L cS R | S | | | | | | | | | | | S | | | Silicone Soft 60 | c L c R | S | | | | | | | | | | | S | | | Silicone Very Soft 40 | c L c R | S | | | | | | | | | | | S | | | Swim Plug – Floatable Silicone | c L c R | | | | | | | | | | | | | | STEP 6: Tube/Connector Details 􀁹 Soft earmolds come standard with prelocked tubing (TRS). 􀁹 Hard earmolds come standard with glued tubing. 􀁹 Tube/Connectors are only available in clear/transparent. 􀁹 13M is standard for acrylic and 13T is standard for silicone. | Tubing | | | | --- | --- | --- | | 13 Medium Tube 13M* | c L | c R | | 13 Thick Wall Tube 13T | c L | c R | | 13 Dry Wall Tube 13D* | c L | c R | | 13 Dry Thick Wall Tube 13W | c L | c R | *Not available with Prelocked Tubing | SlimTube | Please indicate
Tube length
(00*/0/1/2/3) | | | --- | --- | --- | | SlimTube 3.0 (Bolero B, Sky B-M, -P, & -PR) | L | R | | SlimTube 4.0 (Lumity, Paradise, Marvel BTEs) | L | R | | Power SlimTube II (Sky B-SP & -UP, Naida B-SP & -UP) | L | R | **00 only available in SlimTube 4.0 025-0574/Phonak Custom

FAQs

What information is required in Step 1 for placing an order?

Step 1 collects shipping and account details, patient contact name, and age (for pediatric orders), plus the claim type and required claim number.

When is an audiogram required for Acoustically Optimized Venting (AOV)?

The form states that audiogram is required for Acoustically Optimized Venting (AOV). It is also noted as required for AOV orders.

What tube and connector options are available for the earmolds?

Soft earmolds come standard with prelocked tubing (TRS), while hard earmolds use glued tubing. Tube/connectors are available only in clear/transparent, including 13M/13T/13D/13W and SlimTube 3.0/4.0 or Power SlimTube II options with specified tube lengths.

Oct 5, 2026

Uploaded by Cipher