Follow the steps to accurately fill out the CUSTOM DIGITAL ORDER FORM.

1. Press the ‘Get Form’ button to access the CUSTOM DIGITAL ORDER FORM and open it in your preferred document editor.
2. Begin by entering the order number in the designated field at the top of the form.
3. Indicate your dispenser number and the date to ensure accurate record-keeping.
4. Select the model or shell style from the provided options by marking the appropriate box for the right (R) and left (L) hearing aids.
5. If applicable, select any special features for each model, such as 'Invisa' or 'Demo Model', by placing a check in the corresponding boxes.
6. Fill in the shipping information including the name, street address, city, state or province, and ZIP/postal code.
7. Complete the fitter name and fitter number fields to identify the person fitting the devices.
8. Provide the national account number and member ID number if applicable, filling in the required details.
9. Complete the patient information section, including last name, first name, address, phone number, birth date, and email address.
10. Select the appropriate marketing information options to indicate whether you are a new user, prior Beltone user, or competitive user.
11. Fill in the audiogram data section with hearing threshold levels in dB HL for both right and left ears.
12. Detail the impression information including ear consistency and jaw movement for both ears.
13. Select warranty information by checking the box for the desired warranty period.
14. Add any special instructions if necessary, including any changes that might be required.
15. Review all the completed sections for accuracy and ensure all necessary fields are filled.
16. Once finished, save your changes, download the form, print it, or share it as needed.

Complete your documents online today for a smoother ordering experience.