3D re-design request

RE-DESIGN REQUEST FOR NEW MOULD FROM AN EXISTING SCAN

ANY REQUESTS FOR FAST TRACK OR PRIORITY RECEIVED AFTER 10:00 am WILL BE BOOKED IN FOR PROCESSING NEXT WORKING DAY

PLEASE CHECK HERE FOR TYPES THAT ARE 3D SCANNED AND CAN BE REQUESTED USING THIS SERVICE

Complete and submit for a 3D Re-Design request. **Fields with * are mandatory**

RE-DESIGN REQUEST

Clinic/Store Code *

Clinic or Store code for this request

Contact Name *

Please enter your name here so that we may refer back to you with any queries.

Your email address *

Please enter your contact email address (to receive a copy of the submitted request)

Provide accurate details for original Ear mould(s) to assist with locating scan files

Original Clinic/Store *

The original clinic or store the impressions were ordered from

Patient Reference ID *

Please enter patient reference ID

RH Ear - Original No./ID *

Original Right Ear No. or ID ref

LH Ear - Original No./ID *

Original Left Ear ID No. or Ref

Original Mould Type & Mat'l *

Please let us know what the original ear mould type and material was

Original impression date *

If not known please put approximate date

Original Batch Number

Please leave blank if unknown.

Features of original mould

Please add any additional information e,g, colour, vent Size, type of tubing, high powered, double dip)

Additional Details

Any additional details such as mould or scan numbers and dates to help identify the correct moulds

Details of New Ear moulds Required

New Mould Type & Mat'l *

Please let us know the new ear mould type and the material required

RH Ear - New mould *

New Right Ear ID No. or Ref

LH Ear - New Mould *

New Left Ear ID No. or Ref

Features for new mould

Please add any additional information e,g, colour, vent Size, type of tubing, high powered, double dip)

Turnaround Time Required *

Select a turnaround time **CUT-OFF FOR URGENT ORDERS 10am** Urgent orders received after this time will be processed next day.