TF Diagnostic Socket Work Order

Transfemoral Diagnostic 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 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
Cast/ImpressionDiagnostic Socket
No ModificationsNeeds Modifications
Modification Notes
BulldogOrfitrans StiffVivakCoPolyThermolyn
Pe-LiteBockliteProflexOPTek FlexOrfitrans ExcelProflex w/ SiliconeOPTek Flex ComfortOrfitrans Extra Soft w/ SiliconeNorthvane
Ossur Icelock 850RevoLockWillowwood AlphaKISS DelrinBulldogOther
Coyote AirLockCoyote EasyOff LockBulldog 3Genesis (Puck Lock)Bulldog APLFillauer Shuttle LockOssur Icelock 621Ossur Icelock 4-HoleOssure Icelock 562 HybridOther
Ossur 552AK LynAncloteCA AriaCoyote CQLOther
Panels drawn on model2-Panel (specify in notes)3 Panel (specify in notes)4-Panel (specify in notes)Other
Ischial Containment/Narrow M-LSub-IschialDrawn on ModelOther
Socket onlySocket w/ attachment plateSocket w/ attachment plate + reinforcement
Hi-Tek (Aluminum)Willowwood (composite)Bulldog (Aluminum or Stainless Steel))Bulldog Delrin3-Prong4-ProngOther
Bench AlignmentOther
Notes
Should be Empty:

Transfemoral Diagnostic Socket Order Form

Order Information

Measurements

Fabrication Instructions