Lower Extremity Prosthetic Fabrication

CROW Fabrication
CROW
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Today's Date:*

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Due Date:

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CROW Fabrication

Patient Information
Affected Side:*

LeftRight
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CROW Fabrication

Measurements
Build from mold (measurements not required):*

YesNo, correct mold to measurements provided and then modify
Left - Measurements:
Right - Measurements:

CROW Fabrication

Notes
I would like a phone call to discuss this project prior to starting fabrication

Yes
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