Last Name. M52080 Soft healing cap 2 M52080 Soft healing cap 2 Ponto BHX Implant, 4mm *H with abutment, 9mm. After Care Kit M51177

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1 SHIP TO Customer No. (Please complete all information including name and phone number) Phone # Fax # Clinic Name _ Address _ City _ State Zip PO# BILL TO (If different than SHIP TO) Customer No. Company Name Address City _ State Zip _ SHIPPING OPTIONS Standard Next Day (Delivery by 4pm)* Next Day Morning (Delivery by 10:30am)* *Shipping charges apply Next Day Early am (Delivery by 8:30am)* CONTACT INFORMATION Today's Date Contact Name Contact No. Contact Send Confirmation: Yes No PATIENT INFORMATION First Name Last Name Surgeon _Surgery Date RETURN AND EXCHANGE POLICY Oticon Medical Processors & Accessories can be returned or exchanged within 90 days of the shipment date at no charge. To receive a credit, less shipping, handling and insurance charges, please call to request a Return for Credit form. The form must be filled out and returned along with the product. Middle Initial Age PONTO SYSTEM ORDERS Unilateral Ponto BHX UNI1 Stage 9mm QTY One Stage w/ 9 mm Ponto BHX UNI2 Stage 9mm QTY Two Stage w/ 9 mm M50287 Guide drill, 3-4 mm 1 M50287 Guide drill, 3-4 mm 1 M51122 Wide countersink, 4 mm 1 M51122 Wide countersink, 4 mm 1 M50549 Biopsy punch, 4 mm 1 M50549 Biopsy punch, 4 mm 1 M52080 Soft healing cap 1 M52080 Soft healing cap 1 M52169 Ponto BHX Implant 4mm, *H with abutment, 9mm 1 M52173 Ponto BHX Implant, 4mm 1 M50098 Cover screw hexagon 1 M51177 Ponto After Care Kit 1 M50318, 9 mm 1 M51177 Ponto After Care Kit 1 PONTO SYSTEM ORDERS Bilateral Ponto BHX BI1 Stage 9mm QTY One Stage w/ 9 mm Ponto BHX BI2 Stage 9mm QTY Two Stage w/ 9 mm M50287 Guide drill, 3-4 mm 1 M50287 Guide drill, 3-4 mm 1 M51122 Wide countersink, 4 mm 1 M51122 Wide countersink, 4 mm 1 M50549 Biopsy punch, 4 mm 1 M50549 Biopsy punch, 4 mm 1 M52080 Soft healing cap 2 M52080 Soft healing cap 2 M52169 Ponto BHX Implant, 4mm *H with abutment, 9mm 2 M50098 Cover screw hexagon 2 M52173 Ponto BHX Implant, 4mm 2 M51177 Ponto After Care Kit 1 M50318, 9 mm 2 M51177 Ponto After Care Kit 1 Rental Drill RENTAL Rental Drill* *Contains non-disposable instruments and drill After Care Kit M51177 Ponto After Care Kit Contains after care brochure, extra cleaning brush, cotton swabs, wet wipes, abutment covers, mirror and carrying case

2 Minimally Invasive Ponto Surgery Items MIPS Surgery Kits and Items M52207 MIPS Surgery Kit Cannula 1 Cannula guide drill with spacer 1 Cannula widening drill, 4mm 1 Soft healing cap 1 M52329 MIPS Back-Up Surgery Kit Cannula 1 Cannula widening drill, 3mm 1 BioHelix Implants BHX Implants M52172 Ponto BHX Implant, 3mm M52173 Ponto BHX Implant, 4mm M52166 Ponto BHX Implant, 3mm, with abutment, 6mm M52167 Ponto BHX Implant, 3mm, with abutment, 9mm M52168 Ponto BHX Implant, 4mm, with abutment, 6mm M52169 Ponto BHX Implant, 4mm, with abutment, 9mm M52170 Ponto BHX Implant, 4mm, with abutment, 12mm M52171 Ponto BHX Implant, 4mm, with abutment, 14mm Surgical Instruments Non Disposable Instruments M52074 Sterilization Kit M51690 Counter torque wrench M50230 Torque wrench M50437 Handle with screwdriver M50384 Screwdriver, machine, 35 mm M51695 inserter, machine M50386 Square fit connection, machine M50428 Sound processor indicator M50534 Screwdriver hexagon M52143 Ruler M52196 Double-ended dissector M52366 Insertion indicator Disposable Instruments M50287 Guide drill, 3-4 mm M51144 Wide countersink, 3 mm M51122 Wide countersink, 4 mm M50549 Biopsy punch, 4 mm M50550 Biopsy punch, 5 mm M50821 Healing cap M52080 Soft healing cap Allevyn Wound Care Surgical Components M50098 Cover screw hexagon M50349, 6 mm M50318, 9 mm M51149, 12 mm M52063, 14 mm M50362 Angled abutment 10

3 Sound Processors Ponto 3 M52620 Ponto 3, left, diamond black M52621 Ponto 3, right, diamond black M52622 Ponto 3, left, mocca brown M52623 Ponto 3, right, mocca brown M52624 Ponto 3, left, chroma beige M52625 Ponto 3, right, chroma beige M52626 Ponto 3, left, white silver M52627 Ponto 3, right, white silver M52628 Ponto 3, left, steel grey M52629 Ponto 3, right, steel grey M52630 Ponto 3, left, pure white M52631 Ponto 3, right, pure white Ponto 3 Power M52634 Ponto 3 Power, left, diamond black M52635 Ponto 3 Power, right, diamond black M52636 Ponto 3 Power, left, mocca brown M52637 Ponto 3 Power, right, mocca brown M52638 Ponto 3 Power, left, chroma beige M52639 Ponto 3 Power, right, chroma beige M52640 Ponto 3 Power, left, white silver M52641 Ponto 3 Power, right, white silver M52642 Ponto 3 Power, left, steel grey M52643 Ponto 3 Power, right, steel grey M52644 Ponto 3 Power, left, pure white M52645 Ponto 3 Power, right, pure white Ponto 3 SuperPower M52648 Ponto 3 SuperPower, left, diamond black M52649 Ponto 3 SuperPower, right, diamond black M52650 Ponto 3 SuperPower, left, mocca brown M52651 Ponto 3 SuperPower, right, mocca brown M52652 Ponto 3 SuperPower, left, chroma beige M52653 Ponto 3 SuperPower, right, chroma beige M52654 Ponto 3 SuperPower, left, white silver M52655 Ponto 3 SuperPower, right, white silver M52656 Ponto 3 SuperPower, left, steel grey M52657 Ponto 3 SuperPower, right, steel grey M52658 Ponto 3 SuperPower, left, pure white M52659 Ponto 3 SuperPower, right, pure white Sound Processors Ponto Pro Ponto Pro, left, diamond black Ponto Pro, right, diamond black Ponto Pro, left, mocca brown Ponto Pro, right, mocca brown Ponto Pro, left, chroma beige Ponto Pro, right, chroma beige Ponto Pro, left, white silver Ponto Pro, right, white silver Ponto Pro Power M50677 Ponto Pro Power, left, diamond black M50676 Ponto Pro Power, right, diamond black M50873 Ponto Pro Power, left, mocca brown M50872 Ponto Pro Power, right, mocca brown M50875 Ponto Pro Power, left, chroma beige M50874 Ponto Pro Power, right, chroma beige M50903 Ponto Pro Power, left, white silver M50902 Ponto Pro Power, right, white silver WARRANTIES FOR PROCESSORS All processors come with a 2 year repair and 2 year loss, theft, and damage policy standard. EXTENDED WARRANTIES Up to 3 additional years of warranty coverage can be purchased for new processors or processors under a new processor warranty. Add l year repair warranty (no loss) $495 per yr. Add l year extended warranty (with loss) $595 per yr. Add l year Pediatric $549 per yr. Peace of Mind warranty FREE ITEM WITH THE PURCHASE OF A PONTO 3, PONTO 3 POWER, OR PONTO 3 SUPERPOWER. PLEASE CHOOSE ONE OF THE FOLLOWING: Oticon Medical Streamer, black Oticon Medical Streamer, white Additional 1 year of repair warranty (no loss)

4 CONNECTLINE ITEMS AND ACCESSORIES Ponto Streamers Oticon Medical Streamer, black Oticon Medical Streamer, white Power Supply Cradle, black Cradle, white Audio cable kit USB Cable for Streamer Pro Belt clip for Streamer Pro, black Belt clip for Streamer Pro, white Replacement Neck Loops Short neck loop for Streamer Pro, light grey Medium neck loop for Streamer Pro, light grey Long neck loop for Streamer Pro, light grey Short neck loop for Streamer Pro, dark grey Medium neck loop for Streamer Pro, dark grey Long neck loop for Streamer Pro, dark grey Streamer Skins Processor Skins M51820 Ponto skin, right, transparent M51821 Ponto skin, left, transparent M51832 Ponto Power skin, right, transparent M51833 Ponto Power skin, left, transparent M51844 Ponto skin set, right M51845 Ponto skin set, left M51846 Ponto Power and SuperPower skin set, right M51847 Ponto Power and SuperPower skin set, left M52561 Ponto skin set, right M52562 Ponto skin set, left M52563 Ponto Power and SuperPower skin set, right M52564 Ponto Power and SuperPower skin set, left Processor Stickers M52857 Ponto sticker set, right M52858 Ponto sticker set, left M52859 Ponto Power and SuperPower sticker set, right M52860 Ponto Power and SuperPower sticker set, left Streamer Pro skin, black Streamer Pro skin, white Streamer Pro skin with FM port, black Streamer Pro skin with FM port, white Streamer Pro skin with one button white Streamer Pro skin with one button black ConnectLine Items ConnectLine Microphone ConnectLine TV Adapter ConnectLine Phone Adapter ConnectLine, BTD 800 USB Dongle

5 CONNECTLINE ITEMS AND ACCESSORIES Accessories M50446 Telecoil M50377 Audio adapter M50308 Head band M50104 Test band Pediatric Care Kit Mini-Super Dry Aid Zephyr Dry and Store Battery Pack 675P Battery Pack Battery Pack 13 M50290 cover, beige M50294 cover, black Ponto Softband, unilateral, beige Ponto Softband, unilateral, yellow Ponto Softband, unilateral, red Ponto Softband, unilateral, pink Ponto Softband, unilateral, cerise Ponto Softband, unilateral, purple Ponto Softband, unilateral, navy Ponto Softband, unilateral, indigo Ponto Softband, unilateral, blue Ponto Softband, unilateral, turquoise Ponto Softband, unilateral, green Ponto Softband, unilateral, grey Ponto Softband, unilateral, brown Ponto Softband, unilateral, black SoundConnector Accessories Ponto Softband, bilateral, beige Ponto Softband, bilateral, yellow Ponto Softband, bilateral, red Ponto Softband, bilateral, pink Ponto Softband, bilateral, cerise Ponto Softband, bilateral, purple Ponto Softband, bilateral, navy Ponto Softband, bilateral, indigo Ponto Softband, bilateral, blue Ponto Softband, bilateral, turquoise Ponto Softband, bilateral, green Ponto Softband, bilateral, grey Ponto Softband, bilateral, brown Ponto Softband, bilateral, black Warranties for Streamers and ConnectLine Items All Streamers and ConnectLine items come with a 1 year warranty but NO loss and damage. All Streamer Pro accessories listed are compatible with Ponto and Oticon Medical Streamer.