Phonak Service Form - phonakpro.com

1 Phonak Service Form Step 1: Customer Information Step 2: Device Information Ship To Account Number: Date: Device Model/Serial Number: Address: n Receiver (must accompany device) size/side (0 3, L/R): City: State: Zip: n SlimTube (if included) size/side included (00 3, L/R): Bill To Account Number: n Ear hook color: Address: Custom Ear Piece Model/Serial Number: City: State: Zip: n Hearing instrument is not included in this repair Patient Name: Patient is under 21 years of age n (Check box if yes) Complete Step 3 Step 3: RogerDirect Installation Information Third Party Patient Number: Is RogerDirect installed in the paradise /Marvel device? n Yes n No Purchase Order Number: If yes, please select the install method: Contact Name: n Roger X (02) Pediatric Phone Number: n Roger iN Microphone or Roger X (03) Home/Work/University Phone number required for shipping directly to patient or school. We're unable to ship to a Box. Additional charge for shipping directly to the patient.

2 If the patient's settings cannot be restored we will ship back to the sender. Step 4: Service Plan Options Prices subject to change without notice n 24-Hour Service Option [Rush24] 24-hour Service is not guaranteed during holidays; additional fee applies Must select below if out of warranty repair A ll serialized out of warranty items included will be repaired with a 6 month warranty by default. Charges will apply. Out of Warranty cShell & SlimTip will be a chargeable new order. Instruments more than 5 years post invoice date will only be repaired if parts are available. Shipping and handling applies to all chargeable repair orders. DEVICES LESS THAN 5 YEARS POST INVOICE DEVICES LESS THAN 5 YEARS POST INVOICE DEVICES MORE THAN 5 YEARS POST INVOICE. DATE: 6 MONTH WARRANTY DATE: 12 MONTH WARRANTY DATE: UP TO 6 MONTH WARRANTY (or until end n Hearing Instruments/ Phonak CROS 1/ n Hearing Instruments/ Phonak CROS 1/ of Service date).

3 Roger/FM Roger/FM n Hearing Instruments/ Phonak CROS 1/. n Wireless Accessories n Wireless Accessories Roger/FM. n RemoteMic/TVLink n RemoteMic/TVLink n Wireless Accessories n ITE Remake 2 n ITE Remake 2 n RemoteMic/TVLink (In addition to a Service plan, for same model (In addition to a Service plan, for same model n ITE Remake 2. and patient only) and patient only) (In addition to a Service plan, for same model and patient only). Step 5: Reason for Service CUSTOMER REQUEST (CC40 / CC38 / CC39) CONNECTIVITY (CC10) TAMPER-PROOFING (BTE ONLY). Add/remove/change option 3 FM / Roger Tamper-proof battery door (please specify your request in comments field) Wireless / Bluetooth Roger integrated receivers n Change color to: CROS Mini ear hook Programming problem Tamper-proof ear hook (HI Software). RESIDUES (CC17) Telecoil Wax problem BROKEN (CC16). Sweat, moisture, humidity Housing ACOUSTIC RESPONSE (CC11) Battery door Occlusion Volume wheel Service (CC14) Feedback: Internal (not poor fit) Push button Clean & functional check Feedback: Venting diameter Earhook / Soundtube too large Microphone cover HARDWARE / COMPONENTS Feedback: Due to shell fit / Cord or cable cracked / frayed NOT FUNCTIONING (CC10) Not airtight (accessories).

4 Toggle switch Feedback: With jaw movement Shell Canal Lock Faceplate Push button Noisy: Crackling / Popcorn Removal line Volume control Noisy: Static / hissing Wax system Dead Acoustic response too weak Battery contacts Display (accessories) Acoustic response too weak after Receiver wire of cShell feedback test Wires inside device / shell Battery: Intermittent Electronic module / faceplate detached Rechargeable / Not charging Sound fades in/out Receiver detached from Shell (ITE). High drain Distorted Stuck Poor acoustic performances ( venting too large). 1 Please return the Phonak CROS transmitter and hearing instrument for repair for a full evaluation. 2 Remake charges will apply to out of warranty custom hearing instruments with cracks, holes, missing shell and remakes requested for fit issues. Model Change not available if out of trial period. 3 See Price and Reference Guide for chargeable options. Phonak | 750 North Commons Drive | Aurora, IL 60504 | Phone 800-777-7333 | Fax 630-393-9858.

5 Phonak Service Form Step 6: Remake Information Hearing aids, cShells and SlimTips must be included with all remakes. SHELL FIT (CC23) CUSTOM SHELL MODIFICATION (CC38) PLEASE MARK THE PROBLEM AREA. Too big protruding / cosmetics For best fit, please send complete impression Canal too long including second bend Canal too short (IV) Increase Vent Too loose / poor retention (DV) Decrease Vent Too loose / moving in the ear (FE) Feedback Too small dexterity problem (BR) Broken Difficult to insert (OB) Occluded (Barrel sound). Difficult to remove (TF) Tight Fit (Mark and include full new impression, see image). Too tight (LF) Loose Fit Sound bore direction (Mark and include full new impression, see image). (AC) Add Canal Lock 4. (Include full impression. N/A IIC.). HURTS WHERE MARKED (HL) Add Helix Lock 4. (Include full impression. N/A IIC.). Shell (SL) Add Skeleton Lock 4. Lock (Include full impression. N/A IIC.). With static jaw (SC) Add Soft Coat 4.

6 With moving jaw Add Lacquer By inserting / removing device Add Wax Option No Laquer (Beige, Cocoa and Clear only). Canal lock will be the same color as the shell: Transparent, Pink, Brown, Cocoa and Tan only. Notes, Description of Problem, Items Sent with Repair: n Please call before repairing 025-1058/2022-02/hc Sonova USA Inc. All rights reserved. Submit your Service Order on Phonak Store: 4 Chargeable option for hearing instrument. S B R1 R2 L1 L2. Sonova USA Inc. is not responsible and assumes no liability for any non- Phonak manufactured device or accessory sent by you to Phonak . Please ensure that you only include Phonak devices and accessories herein. PNK BLU YLW FLS GRN PRP WHT TRQ. Phonak | 750 North Commons Drive | Aurora, IL 60504 | Phone 800-777-7333 | Fax 630-393-9858.