Socket Order Form

Prosthetic Socket 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 Name *
Shipping Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
DELIVERY METHOD *
Patient Information

For bi-lateral patients, please submit one form for each side
Have a Tech Call Me

Yes
Amputation Side

Left Right
Activity Level
Amputation Level
Cast/Scan Information
Scanned medium
Sending Physical Model?

Yes
FABRICATION INSTRUCTIONS
Device Type: Test Socket
OR Definitive Socket
Inner Socket
Volumetric Modifications
Volumetric Modification Amount
Distal Adapter *
Alignment *
Other Alignment
Component Being Used
Bulldog, KISS, 4-Hole Adapter, etc.
Cosmetic Finish
Cosmetic Details
MEASUREMENTS

All inputted measurements should be in cm

AK Measurements (If Applicable)
IT to Distal End
4” above IT
2” above IT
At IT
2” below IT
4” below IT
6” below IT
8” below IT
10” below IT
12” below IT
14” below IT
16” below IT
18” below IT
AK Socket Shape
ADDITIONAL INFORMATION
Note: Protosthetics can only make products as well as you describe your needs — please be thorough!
Should be Empty:

Prosthetic Socket Order Form