ALL PRICES ARE CONSIDERED ESTIMATES FOR THE PROCEDURES INDICATED. IF ADDITIONAL PROCEDURES ARE NECESSARY, ADDITIONAL CHARGES MAY APPLY UPON INVOICING
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Please allow 10 business days from submission of this form for fabrication
Name
*
Practitioner name
Facility
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Shipping Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Submission date
*
-
Month
-
Day
Year
Date
Requested In Office
*
-
Month
-
Day
Year
Date
Patient name
*
First Initial
Last Name
Affected Side
Please Select
Right
Left
Bilateral
Patient Weight
*
Activity Level
*
*NOTES* (Please indicate ALL cast modifications, alignment changes, cover measurements, special instructions)
My Products
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( X )
Device Type
$
Free
BK
Symes
Lamination
$
450.00
Lamination type
Single shot
Two-stage
None - Accessory fab
Transfer
Transfer alignment for two-stage laminations OR when replacing componentry
$
Free
No
Yes
Cast Modifications
$
Free
No
Yes
Volume Changes
MUST provide appropriately sized ply sock to avoid an additional $50 charge
$
Free
No
Yes
Flexible Interface
$
Free
No
Yes
Material
None
MPE
Proflex
Orfitrans Medium Soft
Orfitrans Excel Clear
Orfitrans Excel Black
Northvane Clear
Finished thickness
0
2-3mm
3-4mm
4-5mm
Soft interface
$
Free
Option
No
Yes
Material
None
BockLite
Pelite
Keasy cone
End pad
Plastazote
$
Free
No
Yes
Thickness
None
1/4"
1/2"
Stovepipe/SC Wedge
$
Free
No
Yes - Wedge
Yes - Stovepipe
Material
None
Bocklite
Pelite
Plastazote
Boa Install
$
Free
No
Yes - 1 Panel
Yes - 2 Panels
Yes - 3 Panels
Yes - Symes/Chopart Door
Yes - Lanyard
Lamination Finish
$
Free
Color
Carbon
Caucasian
Hispanic
African American
Custom Fabric
Symes/Chopart, Door/Clamshell
$
Free
No
Yes - Door
Yes - Clamshell
Yes - Door w/Overlap
Yes - Clamshell w/Overlap
Yes - Door Overlap w/Custom finish
Yes - Clamshell Overlap w/Custom finish
Cosmetic Cover
Sink and shape *Please include measurements in Notes*
$
Free
No
Yes
Material
None
OttoBock firm
Fillauer white
Ohio Willowwood
Laminated Cosmetic Shell/Slip Cover
$
Free
No
Yes - Sleeve protector
Yes - Yes - Sleeve protector(custom finish)
Yes - Cosmetic shell(match socket)
Yes - Cosmetic shell(custom finish)
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