Rekvisisjonsskjema - Namsos Audiosenter
Transcription
Rekvisisjonsskjema - Namsos Audiosenter
Rekvisisjon av ørepropp Merking av ørepropper Venstre (blå) Høyre (rød) V/H Slange feste - hard/myk EH-bend Plast bend Plast vinkel bend (45˙) Tubelock + Etterbehandling - hard/myk Spider Air Chess Beskrivelse av ørepropp/slangefeste Hard propp Myk propp Standard propp Silhuett propp Skall propp Åpen propp Noise canal* Lang kanal Kort kanal Normal kanal 3 3 3 /4 1 /4 1 /4 1 (open moon) 3 /4 1 /2 /2 /2 /2 *(myk propp med støyfilter og tubelock +) Ventilering Åpen propp Tett propp 2 mm ventilering 1 mm ventilering ....mm ventilering Utboring 2 mm utboring 1 mm utboring Horn utboring H V H V H H H V V V H V H V H V Se illustrasjonsbilder på www.namsosaudiosenter.no Forhandler:............................................................................................................................................................................................................................................................................................................................................................................................................ Rekv. høresentral:................................................................................................................................................................................................................................................................................................................................................................................... Pasientnavn:................................................................................................................................................................................................................................................................................................... Født:................................................................ Adresse:...................................................................................................................................................................................................................................................................................................................................................................................................................... Trygdekontor:.................................................................................................................................................................................................................................................................................................................................................................................................. Merknader:............................................................................................................................................................................................................................................................................................................................................................................................................. ......................................................................................................................................................................................................................................................................................................................................................................................................................................................... Sendes høresentral Sendes forhandler Sendes pasient Venstre Høyre Dato:.................................................. Ny time:.......................................... Tlf: 74 27 35 33 • Postboks 504 Sentrum, 7801 Namsos • [email protected]