Transfemoral Laminated Socket Order Form
(269)-615-1643 | john@wamhoffmobilitylab.com
Order Information
Patient Name
*
PO
Date
/
Month
/
Day
Year
Date Needed
/
Month
/
Day
Year
Practitioner
*
Phone/Email
Facility
*
Address
*
Side
*
Please Select
Right
Left
Bilateral
K-Level
Please Select
K1
Low-level K2
High-level K2
Low-level K3
High-level K3
K4
Height
Weight
*
Age
Sex
Please Select
Male
Female
Unspecified
Measurements
Circumference at IT (over liner)
Circumference at 1" below IT (over liner)
Circumference at 2" below IT (over liner)
Circumference at 3" below IT (over liner)
Circumference at 4" below IT (over liner)
Circumference at 6" below IT (over liner)
Circumference at 8" below IT (over liner)
Circumference at 10" below IT (over liner)
Circumference at 12" below IT (over liner)
Proximal ML
Sitting AP
Ischial Tuberosity - Distal End
Perineum - Distal End
Greater Trocahnter - Distal Femur
Ischial Tuberosity - Knee Center
Ischial Tuberosity - Floor
Knee Center - Floor
Fabrication Instructions
Model Type
Cast/Impression
Diagnostic Socket
Modifications
No Modifications
Needs Modifications
Modification Notes
Alignment
Bench Alignment
Transfer Alignment
Other
Lamination Layup
K1
Low Activity K2
Moderate Activity K2
Moderate Activity K3
High Activity K3
K4
Double Wall
Other
Socket Color/Design
Flexible Inner Thickness
1/8" / 3mm
3/16" / 5mm
1/4" / 6mm
3/8" / 8 mm
10mm
1/2" / 12mm
15mm
Flexible Inner Type
Full Length
Full Brim (proximal 1/3 of socket)
Medial Brim (anterolateral to posterolateral
Flexible Inner Material
Pe-lite
Bocklite
Northvane
Proflex
OPTek Flex Comfort
Orfitrans Extra Soft
Ischial Pad Thickness
1/8" / 3mm
3/16" / 5mm
1/4" / 6mm
3/8" / 8mm
10mm
1/2' / 12mm
15mm
End Pad Material
Plastazote
Bocklite
Puff
Lanyard/Lock
Lock Provided
Specify Lock
Specify Lanyard/Lock
Valve (Threaded)
Ossur 552
AK Lyn
CA Aria
Other
BOA/Click Reel
Panels drawn on model
2-Panel (specify in notes)
3 Panel (specify in notes)
4-Panel (specify in notes))
Other
Trimlines
Ischial Containment
Sub-Ischial
Drawn on Model
Other
Componentry
No components, socket only
Components provided by practitioner
New components provided by WML
Socket Attachment Plate
Willowwood (standard)
Bulldog
Ossur
3-Prong
4-Prong
Other
Component Provider
APC
Trulife
Bulldog
Other
Notes
Preview PDF
Submit
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