Transtibial 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
Please enter any/all pertinent measurements
Socket Specifications
Model Type
Cast/Impression
Diagnostic Socket
Modifications
No Modifications
Needs Modifications
Amputation Type
Modification Notes
Alignment
Bench Alignment
Transfer Alignment
Other
Vacuum Forming Method
Bubble/Blister
Drape
Plastic Thickness
1/4"
3/8"
1/2"
5/8"
Plastic Type
Bulldog
Vivak
Thermolyn
CoPoly
Orfitrans Stiff
Socket Design
Please enter a detailed description of the prosthesis below (i.e. windows, trimlines, inserts, pads, locks, valves, etc.)
Socket Attachment
Socket only
Socket w/ attachment plate
Socket w/ attachment plate + reinforcement
Socket Attachment Plate
Willowwood (standard)
Bulldog
Ossur
3-Prong
4-Prong
Other
Notes
Preview PDF
Submit
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