Pectus Carinatum Brace Order Form

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# *
Facility *
Shipping Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
DELIVERY METHOD *
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 *
Anterior Panel Shape *
Foams

Choose one for center panels, and one for side panels
A/P Center Panel Foams EVA (1/4”)
OR P-Cell (1/2”)
Side Panel Foams: EVA (1/4”)
OR P-Cell (1/2”)
Aluminum Bar *
Add Shoulder Straps (+$50) *
Xiphoid to Inferior Scapula (Over Shoulder, For Shoulder Straps)
Add Anterior Gel Pad (+$25)
Add iButton Sensor (+$135)
Screenshots of panel layout for approval
ADDITIONAL INFORMATION
Note: Protosthetics can only make products as well as you describe your needs — please be thorough!
Should be Empty:

Foams