Transfemoral Diagnostic 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 Perineum
Circumference at 1" / 2.5cm below Perineum
Circumference at 2" / 5cm below Perineum
Circumference at 3" / 7.5cm below Perineum
Circumference at 4" / 10cm below Perineum
Circumference at 6" / 15cm below Perineum
Circumference at 8" / 20cm below Perineum
Circumference at 10" / 25cm below Perineum
Circumference at 12" / 30cm below Perineum
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
Plastic Type
Bulldog
Orfitrans Stiff
Vivak
CoPoly
Thermolyn
Flexible Inner Material
Pe-Lite
Bocklite
Proflex
OPTek Flex
Orfitrans Excel
Proflex w/ Silicone
OPTek Flex Comfort
Orfitrans Extra Soft w/ Silicone
Northvane
Lanyard
Ossur Icelock 850
RevoLock
Willowwood Alpha
KISS Delrin
Bulldog
Other
Lock
Coyote AirLock
Coyote EasyOff Lock
Bulldog 3Genesis (Puck Lock)
Bulldog APL
Fillauer Shuttle Lock
Ossur Icelock 621
Ossur Icelock 4-Hole
Ossure Icelock 562 Hybrid
Other
Valve (Threaded)
Ossur 552
AK Lyn
Anclote
CA Aria
Coyote CQL
Other
Revo/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/Narrow M-L
Sub-Ischial
Drawn on Model
Other
Socket Attachment
Socket only
Socket w/ attachment plate
Socket w/ attachment plate + reinforcement
Socket Attachment Plate
Hi-Tek (Aluminum)
Willowwood (composite)
Bulldog (Aluminum or Stainless Steel))
Bulldog Delrin
3-Prong
4-Prong
Other
Alignment
Bench Alignment
Other
Notes
Preview PDF
Submit
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