Pectus Carinatum Brace Order Form
If you need any assistance, email success@protosthetics.com or call us at (701)-478-2001
Practitioner Name
*
First Name
Last Name
Practitioner Email
*
example@example.com
PO#
*
Need By
-
Month
-
Day
Year
Date
Facility
*
Shipping Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DELIVERY METHOD
*
Please Select
Ground
2-day (additional charges)
Overnight (additional charges)
Local Pickup
PATIENT INFORMATION
Diagnosis/Special Instructions
Diagnosis/Special Instructions
Have a Tech Call Me
FABRICATION INSTRUCTIONS
Length of Deformity (cm)
Width of Deformity (cm)
Circumference at Xiphoid (cm)
Panel Color
*
Please Select
—
Black
White
Grey
Blue
Green
Orange
Red
Anterior Panel Shape
*
Please Select
Standard
I-Shape (Female)
Foams
Choose one for center panels, and one for side panels
A/P Center Panel Foams EVA (1/4”)
Please Select
—
Black
Black/Grey Swirl
Blue/White Swirl
Teal
Red
Pink Purple White Camo
Green Camo
Yellow Red Blue Green Swirl
OR P-Cell (1/2”)
Please Select
—
Light Blue
Silver
Beige
Black
Side Panel Foams: EVA (1/4”)
Please Select
—
Black
Black/Grey Swirl
Blue/White Swirl
Teal
Red
Pink Purple White Camo
Green Camo
Yellow Red Blue Green Swirl
OR P-Cell (1/2”)
Please Select
—
Light Blue
Silver
Beige
Black
Aluminum Bar
*
Please Select
Anterior (standard)
Anterior & Posterior (+$25)
Add Shoulder Straps (+$50)
*
Please Select
No
Black
White
Xiphoid to Inferior Scapula (Over Shoulder, For Shoulder Straps)
Add Anterior Gel Pad (+$25)
Please Select
—
Yes
Add iButton Sensor (+$135)
Please Select
—
Yes
Screenshots of panel layout for approval
Yes
ADDITIONAL INFORMATION
Note: Protosthetics can only make products as well as you describe your needs — please be thorough!
Preview PDF
Submit
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