TF Laminated Socket Work Order

Transfemoral 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 K3K4Double WallOther
Socket Color/Design
Flexible Inner Type

Full-LengthProximal Brim (proximal 1/3 of socket)Medial Brim (anterolateral to posterolateral)
Flexible Inner Material

Pe-liteBockliteProflexOPTek FlexOrfitrans ExcelProflex w/ SiliconeOPTek Flex Comfort (white)Orfitrans Extra Soft w/ SiliconeNorthvane
Ischial Pad Thickness

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

PuffPlastazoteBocklitePe-Lite
Lanyard

Ossur Icelock 850RevoLockWillowwood AlphaKISS DelrinBulldogOther
Lock

Coyote AirlockCoyote EasyOff LockBulldog 3Genesis (Puck Lock)Bulldog APLFillauer Shuttle LockOssur Icelock 621Ossur Icelock 4-HoleOssur Icelock 562 HybridOther
Valve (Threaded)

AK LynOssur 552AncloteCypress Adaptive AriaCoyote CQLOther
Revo/Click Reel

Panels drawn on model2-Panel (specify in notes)3 Panel (specify in notes)4-Panel (specify in notes)
Panel Placement

AnteriorPosteriorMedialLateralProximal Gap (specify in notes)
Panel Placement Notes
ClickReel Placement Notes
Trimlines

Ischial Containment/Narrow M-LSub-IschialDrawn on ModelOther
Socket Attachment Plate

Hi-Tek (aluminum)Willowwood (composite)Bulldog (aluminum or stainless steel)Bulldog (Delrin)3-Prong4-ProngOther
Componentry

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

Hi-TekBulldogAPCTrulifeOther
Notes
Should be Empty:

Transfemoral Laminated Socket Order Form

Order Information

Fabrication Instructions