TT Laminated Socket Work Order

Transtibial Laminated Socket Order Form

(269)-615-1643 | john@wamhoffmobilitylab.com
Order Information
Patient Name*
PO
Date

MonthDayYear
Date Needed

MonthDayYear
Practitioner*
Phone/Email
Facility*
Address*
Side*
K-Level
Height
Weight*
Age
Sex
Fabrication Instructions
Model Type

Cast/ImpressionDiagnostic Socket
Modifications

No ModificationsNeeds Modifications
Modification Notes
Alignment

Bench AlignmentTransfer AlignmentOther
Lamination Layup

K1Low Activity K2Moderate Activity K2Moderate Activity K3High Activity K3K4
Lamination Layup

CarbonNon-Carbon (Basalt)Non-Carbon (NSP)
Socket Color/Design
Flexible Inner Type

Full LengthProximal ThirdPosterior Brim Only
Flexible Inner Material

Pe-liteBockliteProflexOPTek FlexOrfitrans ExcelOssurFlexProflex w/ SiliconeOPTek Flex ComfortOrfitrans Extra Soft w/ SiliconeNorthvane
End Pad Thickness

1/8" / 3mm3/16" / 5mm1/4" / 6mm3/8" / 8mm10mm1/2' / 12mm15mm
End Pad Material

PlastazoteBocklitePe-LiteSilicone
Lock

Coyote AirLockCoyote EasyOffBulldog 3Genesis (Puck Lock)Fillauer Shuttle LockOssur Icelock 621Ossur Icelock 4-HoleOssur Icelock 562 HybridOther
Valve (Threaded)

KISSBK LynOssur 551Ossur VacuValveCypress Adaptive AriaOther
Valve (Distal Expulsion)

Bulldog TP5Ossur Icelock 544Cypress Adaptive Aria HV PlateOther
Revo/Click Reel

Panels drawn on model1 Panel (Gastroc)3 Panel (Gastroc + Tibs)Other
ClickReel Placement
Include additional notes here
Vacuum

LimbLogicHarmonyOther
Trimlines

StandardDrawn on ModelOther
Socket Attachment Plate

Hi-Tek (Aluminum)Willowwood (composite)Bulldog (Aluminum or Stainless Steel)Bulldog (Delrin)3-Prong4-ProngWML ChoiceOther
Componentry

No components, socket onlyComponents provided by practitionerNew components provided by WML
Component Provider

Hi-TekBulldogAPCTrulifeOther
Notes
Should be Empty:

Transtibial Laminated Socket Order Form

Order Information

Fabrication Instructions