Transtibial Definitive Socket Fabrication
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Patient Name:
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First Initial
Last Name
PO #:
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Practitioner:
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Clinic Location:
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Big Rapids (781800)
Bloomington (317000)
Carmel (317100)
Charlotte (318500)
Charlotte (477800)
Columbus (317200)
Danville (317700)
Evansville (317300)
Fort Wayne (006100)
Greenwood (317400)
Holland (016800)
Indianapolis (317500)
Jackson (013700)
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
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Today's Date:
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Month
 -
Day
Year
Date
Due Date:
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Month
 -
Day
Year
Date
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Transtibial Definitive Socket Fabrication
Patient Information
Weight:
*
Age:
*
Affected Side:
*
Left
Right
K-Level:
*
K1
K2
K3
K4
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Transtibial Definitive Socket Fabrication
Alignment
Method of Transfer:
*
Neutral (All Planes)
Transfer From Components
Transfer From Lines
I need to make changes to my alignment:
Transverse Changes
Coronal Changes
Sagittal Changes
Transverse Changes:
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Internally Rotate Foot
Externally Rotate Foot
Number of Degrees:
Coronal Changes (Angular):
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Abduct Socket
Adduct Socket
Number of Degrees:
Coronal Changes (Linear):
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Inset Knee/Foot
Outset Knee/Foot
Number of Inches:
Sagittal Changes (Angular):
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Flex Socket
Extend Socket
Number of Degrees:
Sagittal Changes (Linear):
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Anterior Shift Foot
Posterior Shift Foot
Number of Inches:
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Transtibial Definitive Socket Fabrication
Modifications
I need plaster modifications:
*
Yes
No
Decrease Model:
Globally (standard)
Circumferentially
Increase Model:
Globally (standard)
Circumferentially
Amount of Change:
1 Ply
2Ply
3 Ply
5 Ply
Other
Follow instructions on diagnostic socket (for modifications only)
Areas needing plaster mods marked on diagnostic socket
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Transtibial Definitive Socket Fabrication
Suspension / Distal Attachment
Suspension:
*
Shuttle Lock
Suction/Vacuum
Suction/Vacuum:
*
Plate with distal valve included
Valve mounted on the socket
Shuttle Lock:
*
65mm 4-Hole (Bulldog style)
Bulldog APL (for offsets)
Ossur 562 Hybrid
Coyote AirLock
Other
Coyote Air Lock Depth:
*
Regular for 8-click pin
Deeper for 11-click pin
Lanyard:
*
65mm 4-Hole (KISS style)
Delrin Base (for offsets)
RevoLock Align (mark reel location)
RevoLock 4-Hole (mark reel location)
Suction/Vacuum Integrated Plates:
*
Ossur 544 Plate (includes valve)
Cypress Plate (includes valve)
Tube Cutout (includes barb for hose)
Heavy Duty 450lb Rated (Trulife AAASMP450)
Other
Suction/Vacuum Push Button Auto Expulsion Valves (socket mounted):
*
Ossur Icelock 551
Aria Valve Plus (CA200-AVPM)
Other
Basic Distal Attachments:
*
4-Hole Plate (no valve)
Crows Foot (three prong)
Basic 4-Hole Plate:
*
Standard 9.5mm "low-profile" (Bulldog FHLA-3)
Square Shaped 11mm (Bulldog FHLAS-11)
Heavy Duty 450lb Rated (Trulife AAASMP450)
Crows Foot:
*
Low-profile 9.5mm crows foot
Deep depth 14mm crows foot (use with OB rotator or similar)
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Transtibial Definitive Socket Fabrication
Inner Liners
Inner Liner Type:
*
No Inner Liner
Flexible Plastic - Full
Flexible Plastic - Proximal Only
Soft/Foam Inner Liners
Soft/Foam Inner Liners:
*
Keasy Cone
Bocklite (Tan) 6mm, w/distal pad
Pelite (White) 8mm, w/distal pad
Flexible Type/Method:
*
Seam/Drape Formed
Bubble/Blister Formed
Seam/Drape Formed Thickness:
*
1/8"
3/16"
Bubble/Blister Formed Thickness (thickness may vary depending on limb shape/size):
*
~1/8"
~3/16"
Seam/Drape Formed Color/Material:
*
Black - Op-Tek Flex (no silicone)
White - Op-Tek Flex Comfort (with silicone)
Bubble/Blister Formed Color/Material:
*
Black - Orfitrans Excel (no silicone)
White - Orfitrans Extra Soft (with silicone)
Orfitrans Medium-Soft (stiff material, opaque white, no silicone)
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Transtibial Definitive Socket Fabrication
Add-Ons and Trim
Amount of Inner Liner Exposed:
*
1/4"
1/2"
1"
Leave 1/4" at Shelf
Leave Flush at Shelf
Inner Liner Attachment Method:
*
Double Sided Tape
Velcro
Chicago Screw
Lamination Dots
No Attachment
Add-Ons (as marked):
RevoFit System
Window(s)
Door (overlapping)
Felt in lamination
One System (fabricated to OWW standards)
Internal Sealing Sleeve (ISS)
Internal Sleeve Thickness:
*
2mm
3mm
Use provided sleeve
Shrouded Stand-alone Valve:
*
Yes
No
Lamination Underneath Valve:
*
Yes
No
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Transtibial Definitive Socket Fabrication
Lamination/Finishing/Add-Ons
Finish:
*
Carbon Fiber
Skin Tone
CFAB Fabric Designs
Fabric Provided by Patient/Practitioner
Carbon Fiber:
*
Black (standard)
add Blue Pigment
add Red Pigment
add Green Pigment
Skin Tone:
*
Caucasian (#2)
Suntan (#R25)
Latino (#R45)
Light Brown (#R49)
Medium Brown (#16)
Dark Brown (#18)
PRS Pigment Swatch #___
CFAB Fabric Designs:
*
Please Select
Vintage Tie-Dye
Hologram Foil
Tropical Flowers (Discontinued)
Silver Sparkle
Pink Sparkle
Light Blue Sparkle
Colorful Feathers (Discontinued)
Polka Dots
Multi Swirls
Daisy
Outer Space
American Flags
Bubbles (Discontinued)
White Lightning
Blue Lightning
Orange Flames
Blue Flames
Green Digital Camo
Grey Digital Camo
Real Woods Camo
Wood Grain
Carolina Panthers
Louisville Cardinals
Indianapolis Colts
Indiana Hoosiers
Kentucky Wildcats
Fabric Provided by Patient/Practitioner:
*
Please provide a brief description of the fabric provided with the socket and any special placement requests.
Single Color Vinyl Decal Design
Please describe or attach a single color design that is not overly intricate or detailed. Design will be placed permanently under resin.
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Transtibial Definitive Socket Fabrication
Notes
I would like a phone call to discuss this project prior to starting fabrication
Yes
Notes:
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