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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:

PO#: i 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 □ Right 761 Rechargeable Mini RIE (limit two per order, includes 767 Mini BTE (limit two per order) one Portable Charging Case) 777 Standard BTE (limit two per order) Portable Charging Case (additional, if desired) 788 Power BTE (limit two per order) 761 Mini RIE (limit two per order) Color: 762 RIE (limit two per order) Gloss Black Dark Brown Sterling Gray Color: Light Blonde Pearl White Medium Blonde Gloss Black Dark Brown Sterling Gray Beige Monza Red Black Light Blonde Pearl White Medium Blonde Anthracite Ocean Blue Gloss Anthracite Beige Monza Red Black Silver Gloss Medium Blonde Anthracite Ocean Blue Gloss Anthracite Silver Gloss Medium Blonde Power Level: Low Power Medium Power High Power Tube Length: 0 1 2 3 4 Receiver Dome Style (pack of 10): Tulip: One size Open: Small Medium Large Power: Small Medium Large

05 ReSound ENZO Q Smart Hearing Aid Select appropriate model and options. Enter quantity below.

BTE Models Side: □ Left □ Right Color: Gloss Black Dark Brown Sterling Gray 788 High Power BTE (limit two per order) Light Blonde Pearl White Medium Blonde 798 Super Power BTE (limit two per order) Beige Anthracite Silver Black

Policy:

This form may be submitted along with a new Nucleus CI System order or any time after a Nucleus recipient's initial activation. Android, Google Play and the Google Play logo are trademarks of Google LLC. The Android robot is reproduced or modified from work created and shared by Google and used according to terms described in the Creative Commons 3.0 Attribution License.

©2021. Apple, the Apple logo, FaceTime, Made for iPad logo, Made for iPhone logo, Made for iPod logo, iPhone, iPad Pro, iPad Air, iPad mini, iPad and iPod touch are trademarks of Apple Inc., registered in the U.S. and other countries. App Store is a service mark of Apple Inc., registered in the U.S. and other countries.

ReSound is part of the GN group. GN makes life sound better through intelligent audio solutions. Please seek advice from your health professional about treatments for hearing loss. Outcomes may vary, and your health professional will advise you about the factors which could affect your outcome. Always read the instructions for use. Not all products are available in all countries.

©Cochlear Limited 2021. All rights reserved. Hear now. And always and other trademarks and registered trademarks are the property of Cochlear Limited or Cochlear Bone Anchored Solutions AB. The names of actual companies and products mentioned herein may be the trademarks of their respective owners.

FUN2947 ISS9 MAY21

Submit completed form to: [email protected] • 1 303 790 1157 (fax)