sonnet registration card - medelkatalogen · audiologist speech and language therapist internet...
TRANSCRIPT
Cochlear Implants
SONNET Registration Card
AW31312_3.0 (English)
Product and Implantation Data
User Information
DD MM YYYY
DD MM YYYY
DD MM YYYY
Control unit serial number
FineTuner serial number
Date of first fitting
Date of birth
Implantation date
Implant serial number
Name of audiologist or clinical engineer
Name of clinic and address
First name
Last name
Address
Postal code
Country
Phone
City
Implanted side
left right
Coil serial number
User Survey
DD MM YYYY
Date of onset of deafnessCause(s) of deafness
SignatureDate
Why did you choose a cochlear implant?
Why did you choose MED-EL?
How did you learn about MED-EL? (Please choose one answer only)
ENT physician Other CI users School / Educational facility
Audiologist Speech and language therapist Internet
Hearing aid acoustician Other:
I hereby give my consent that the personal data mentioned under User Information can be processed by MED-EL Elektromedizinische Geräte GmbH, Innsbruck and their affiliated companies for internal use for after care. That data will not be disclosed to third parties. The consent is given voluntarily and subject to revocation to the extent further processing is not necessary.
To ensure contractual warranty coverage of your audio processor, please complete this form and return it in the envelope provided to:
MED-EL Elektromedizinische Geräte GmbHFürstenweg 77a6020 Innsbruck, AustriaTel: +43 (0) 5 77 88Fax: +43-512-29 33 [email protected]
Yes, I want to be informed about product innovations and news on the cochlear implant system. I hereby give my consent to be contacted until further notice.
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