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
Measurements
Circumference at MPT (over liner)
Circumference at 1" below MPT (over liner)
Circumference at 2" below MPT (over liner)
Circumference at 3" below MPT (over liner)
Circumference at 4" below MPT (over liner)
Circumference at 5" below MPT (over liner)
Circumference at 6" below MPT (over liner)
Circumference at 7" below MPT (over liner)
Circumference at 8" below MPT (over liner)
Condylar ML
Proximal ML
AP at MPT
MPT to Distal Tibia
Residual Limb Length
MPT to floor
Thigh Circumference
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 K3K4Other
Socket Color/Design
Flexible Inner Thickness

1/8" / 3mm3/16" / 5mm1/4" / 6mm3/8" / 8 mm10mm1/2" / 12mm15mm
Flexible Inner Material

Pe-liteBockliteNorthvaneProflexOPTek Flex ComfortOrfitrans Extra Soft
End Pad Thickness

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

PlastazoteBocklitePuff
Lock

Lock ProvidedSpecify Lock
Specify Lock
Valve (Threaded)

KISSOssur 551BK LynCypress Adaptive AriaOther
Valve (Distal Expulsion)

Ossur Icelock 544Willowwood Alpha Distal ExpulsionCypress Adaptive Aria HV PlateOther
BOA/Click Reel

Panels drawn on model3 Panel (Gastroc + Tibs)4 Panel (2 Gastroc + TibsOther
Vacuum

LimbLogicHarmonyOther
Trimlines

StandardDrawn on ModelOther
Componentry

No components, socket onlyComponents provided by practitionerNew components provided by WML
Socket Attachment Plate

Willowwood (standard)BulldogOssur3-Prong4-ProngOther
Component Provider

APCTrulifeBulldogOther
Notes
Should be Empty:

Transtibial Laminated Socket Order Form

Order Information

Measurements

Fabrication Instructions