PL
OPEN FIT ORDER FORM
Prairie Labs, Inc.
P.O. Box 829 • Hopkins, MN 55343
637 12th Ave. South • Hopkins, MN 55343
Toll Free: 1-800-322-8238 Local [952] 908-7654 • Fax [952] 908-7661
Website: www.prairielabs.com Email: prairielabs@tds.net
Acct.#:
Tel #:
Amount Enclosed:
Dealership Name & Address
Check #:
Shipping Address
Patient’s Name:
Patient’s Hearing Information
125 250 500
MODEL
G Freedom 4 (Mini OTE 10A Battery W/Flex Strip Programming)
G Liberty (Convertible OTE/BTE 13 Battery W/Socket Programming)
G BTE with Ear Hook (Liberty Only)
G Open Fit Version
CASE COLOR
Freedom 4
G Beige
G Black
Liberty
G Beige
G Lt. Brown G Cocoa Brown
G Gray G Blue
G Red
G Charcoal
G 2 Tone Beige Case with Brown Insert
TUBES (Side, Size & Quantity)
G Right
G Left
G 0B___
G 0B___
Date:
G 1B___
G 1B___
G 2B___
G 2B___
G 3B___
G 3B___
DOMES (Size & Quantity)
G Small ____
G Medium____
G Large____
* See Reverse Side for Custom Ear Mold & Open Fit Mold Options
*First Tube & Dome Included at No Charge
Additional Tubes, Domes may be purchased
R G
L STD. T-Coil
G
R
L STD. Auto T-Coil
GG
2K
4K
8K
LEFT:
0
10
20
30
40
50
60
70
80
90
100
110
SRT ______
MCL ______
UCL ______
Score ______
RIGHT:
SRT ______
MCL ______
UCL ______
Score ______
HL
SPL
G
G
IMPORTANT:
PLEASE ENCLOSE AN AUDIOGRAM
WITH ORDERS
FIRST ORDER PLEASE SEND
G Cable G Software G Manual G Fitting Tool
* One of Each Included with your First Order
* Additional Cables, & Fitting tool can be purchased
PRAIRIE IMPRESSIONS
DIRECTIONAL MICROPHONE/T-COIL
R G
L Omni/Dir. Dual Mic (user selectable)
G
R G
L AMP. T-Coil (Liberty Only)
G
R G
L AMP. Auto T-Coil (Liberty Only)
G
1K
G Silicone Impression Material ________qty.
* Factory Fresh Material
*Each Kit Makes Up to 55 Impressions
* 2-Part Silicone Kit
* Cures Within 5-7 Minutes
*Auto T-Coil & Omni/Directional Mic cannot be combined
*Additional Shipping Charges Apply
WARRANTY & SERVICE UPGRADES
G Two-Year Warranty (Loss & Damage Included) G One Day In-House Service G Same Day Service
METHOD OF SHIPPING:
G Free First Class Mail
G Priority Mail $5.50
G FedEx Ground $5.50 G FedEx 2nd Day $8.00 G C.O.D. $15.00 G Ins. & Hand per aid $3.00
G Ship To User $6.00 G FedEx Standard Overnight - Actual Price
G Express Account per aid $12.00
PLEASE SEND MORE
G Custom Production Forms
G Repair Forms
G Impression Boxes
G Mailing Labels
G BTE/Ear Mold Production Forms
G FedEx Labels (Express Account Customers Only)
SPECIAL INSTRUCTIONS
Effective May 1, 2008
1 YEAR WARRANTY (INCLUDES LOSS & DAMAGE)
BTE & EARMOLD ORDER FORM
PL
P.O. Box 829 • Hopkins, MN 55343
637 12th Ave. South • Hopkins, MN 55343
Toll Free: 1-800-322-8238 Local [952] 908-7654 • Fax [952] 908-7661
Website: www.prairielabs.com Email: prairielabs@tds.net
Prairie Labs, Inc.
Acct.#:
Tel #:
Amount Enclosed:
Dealership Name & Address
Check #:
Shipping Address
Patient’s Name:
Patient’s Hearing Information
DIGITAL CIRCUITRY
NON-PROGRAMMABLE
125 250 500
PROGRAMMABLE
R G
R G
L PS 1 AGC-I
L PS 1 AGC-I PWR
G
G
R
R
L
L PS 1 Linear PWR
G G PS 1 Linear G G
R
L PS 2 Non-Prog.
GG
R G
L PS 4 Prog.
G
R
L PS 2 Prog.
GG
ANALOG CIRCUITRY
R G
L Class A
R G
L Low Drain A
G
G
R G
L AGC
R G
L AGC/Class D
G
G
R G
L Push-Pull
G
R G
L Class D
G
BTE CASE COLOR
G Beige
G Cocoa Brown
PS 1/ANALOG
GG
R G
L Output Limiter
G
R
L Gain Pot (Linear)
GG
R
L FBR (High Cut)
GG
R G
L Tone (Low Cut)
G
L Threshold (AGC-I)
1K
GG
R G
L STD. T-Coil
G
R
L STD. Auto T-Coil
GG
L
4K
8K
LEFT:
SRT ______
MCL ______
UCL ______
Score ______
RIGHT:
SRT ______
MCL ______
UCL ______
Score ______
HL
SPL
G
G
IMPORTANT:
PLEASE ENCLOSE AN AUDIOGRAM
& IMPRESSIONS WITH ORDERS
PS 2 Non-Programmable
R G
L Low-Chan. TH
L Hi-Cut
GG
G
EARMOLD STYLES
R G
R G
L Hi-Chan. TH
L M.P.O.
G
G
R G
R G
R G
L Full Shell
L Half Shell G
L Skeleton
R G
R G
L Low-Chan. Ratio G
L Low-Cut Slope
G
G
G
R
R
L
L
R
L CIC
Canal
Open
Fit
R G
R G
L Hi-Chan. Ratio
L Trimmer Gain
GG
GG
GG
G
G
R G
R G
L Low-Cut Corner G
L Feedback Notch
G
EARMOLD OPTIONS
R
DIRECTIONAL MICROPHONE/T-COIL
R
2K
0
10
20
30
40
50
60
70
80
90
100
110
TRIMPOTS (choose up to 2 pots)
R
Date:
Omni/Directional (user selectable)
G G Full Time (no switch)
R G
L AMP. T-Coil
G
R G
L AMP. Auto T-Coil
G
R
L
*Auto T-Coil & Omni/Directional Mic cannot be combined
WARRANTY & SERVICE UPGRADES
G Two-Year Warranty (Loss & Damage Included)
G One-Day In-House Service
G Same Day Service
G Deluxe Presentation Kit (Non Returnable)
Color:
G Pink G Beige G Lt. Brown G Cocoa Brown
G Dk. Brown G Hypoallergenic (Clear) G Red/Blue
G G Short Canal
R G
L As Marked
G
R
L
Canal:
R G
L Med. Canal
L Long Canal
GG
G
R G
R G
L Soft Tip
L Bell Canal
G
G
R
Vent:
R G
L None
R G
R G
L Pressure G
L #2 Medium
G
G
R
L
Iros
R
R
L
L Factory Choice
G G Select-A-Vent G G
GG
METHOD OF SHIPPING:
G Free First Class Mail
G Priority Mail $5.50
G FedEx Ground $5.50 G FedEx 2nd Day $8.00 G C.O.D. $15.00 G Ins. & Hand. per aid $3.00
G Ship To User $6.00 G FedEx Standard Overnight - Actual Price
G Express Account per aid $12.00
PLEASE SEND MORE
G Custom Production Forms
G Repair Forms
G Impression Boxes
G Mailing Labels
G BTE/Ear Mold Production Forms
G FedEx Labels (Express Account Customers Only)
SPECIAL INSTRUCTIONS
Effective May 1, 2008
1 YEAR WARRANTY (INCLUDES LOSS & DAMAGE)
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