US 1 of 2 Cochlear Americas Nucleus® Bimodal Solution Order Form PLEASE FILL OUT ALL FIELDS UNLESS INDICATED OTHERWISE. The Nucleus Bimodal Solution is available to all recipients of a Nucleus cochlear implant system. For iPhone® and Android™ bimodal streaming, ReSound LiNX Quattro™ and ReSound ENZO Q™ models are the Smart Hearing Alliance preferred offering until ReSound ONE™ allows for bimodal streaming with Apple® devices late summer. ReSound ONE will return to the order form when compatibility with iPhone is accomplished. For questions related to your order or if your patient requires a different model hearing aid, please contact ReSound: 1 800 248 4327. 01 Patient Information Name: Address: Email: City/State: Zip: Date of Birth: □ New System □ Existing Recipient 02 Billing Information 03 Shipping Information GN Account Number*: G Office: Office: Address: Address: City/State: Zip: City/State: Zip: i PO#: Earmolds are not available through the Cochlear Bimodal Contact Name/Audiologist: Solution Hearing Aid order form. Please order your ReSound earmolds on My ReSound Online (myresoundonline.com) through Email/Phone: the New Earmold Ordering link or the vendor of your choice. If Cochlear Programming Facility: an encased Ultra Power receiver is required please reach out to ReSound directly at 1 800 248 4327. Submit completed form to:
[email protected] • 1 303 790 1157 (fax) 2 of 2 04 ReSound LiNX Quattro Smart Hearing Aid Select appropriate model and options. Enter quantity below. RIE Models BTE Models Side: □ Left □ Right Side: □ Left