3D Printed Transtibial Diagnostic
TT 3D
Please Select
TT 3D
Patient Name
*
First Initial
Last Name
PO #
*
Practitioner
*
Clinic Location
*
Please Select
Big Rapids (781800)
Bloomington (317000)
Carmel (317100)
Charlotte (318500)
Charlotte (477800)
Columbus (317200)
Danville (317700)
Evansville (317300)
Fort Wayne (006100)
Greenwood (317400)
Greenville (786900)
Holland (016800)
Indianapolis (317500)
Indianapolis (780600)
Indianapolis (780800)
Kalamazoo (780300)
Kokomo (785700)
Lexington (317800)
Lexington (007900)
London (317900)
Louisville I (318000)
Louisville II (318100)
Louisville III (008100)
Marquette (787400)
Monroe (318700)
Mooresville (318800)
Morehead (318200)
Mt. Sterling (318300)
Paducah (318400)
Petoskey (787700)
Seymour (317600)
Somerset (319100)
Somerset (028100)
South Bend (765100)
Support Center (318900)
Email
*
Please enter to receive confirmation.
Today's Date
-
Month
-
Day
Year
Date
Due Date
-
Month
-
Day
Year
Date
REVISION TO EXISTING DIAGNOSTIC
Yes
Affected Side
Back
Next
3D Printed Transtibial Diagnostic
Patient Information
Weight
*
Age
*
Affected Side
*
Left
Right
Scan Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Already Modified by Clincian?
Yes
Back
Next
3D Printed Transtibial Diagnostic
Measurements *REQUIRED*
AP
*
ML
*
PML
*
Length
*
MPT to Distal
Circumferences
Back
Next
3D Printed Transtibial Diagnostic
Modifications to Scan
PTB
Shape:
Straight
Arc
Depth
*
1/8"
3/16"
1/4"
Other
Pre-Tib Mods
Depth:
Standard
Custom
Custom Values
Anterior Distal Tibia
Build up:
1/8"
3/16"
1/4"
Other
Fibular Head
Build up:
1/8"
3/16"
1/4"
Other
Back
Next
3D Printed Transtibial Diagnostic
PML Width
Reduce Medial:
1/8"
3/16"
1/4"
Other
Reduce Lateral:
1/8"
3/16"
1/4"
Other
Global Modifications
Increase
Percentage
Ply
Decrease
Percentage
Ply
Percentage Increase
*
2%
3%
4%
Other
Ply Increase
*
1
3
5
Other
Ply Decrease
*
1
3
5
Other
Percentage Decrease
*
2%
3%
4%
Other
Back
Next
3D Printed Transtibial Diagnostic
Socket Length
Increase by
Decrease by
Increase Amount (Inches)
*
Decrease Amount (Inches)
*
Shelf
Style
*
Straight
Slant
W
Already modified
Placement
*
At PTB
Above PTB
Below PTB
Already modified
Below PTB
*
1/4"
1/2"
3/4"
Above PTB
*
1/4"
1/2"
3/4"
Back
Next
3D Printed Transtibial Diagnostic
Trimlines
*
Standard (65 mm)
Extended (75 mm)
Supracondylar (90 mm)
Already modified
Suprapatellar
Material
PETG
CPX
CPX Color
*
White
Black
Suspension
*
Pinlock (65 mm)
Suction/Vac
Other
Corrugation
Extra Charge
Added to the Proximal "Wings"
Notes
Submit
Should be Empty: