AK Fab Form

ALL PRICES ARE CONSIDERED ESTIMATES FOR THE PROCEDURES INDICATED. IF ADDITIONAL PROCEDURES ARE NECESSARY, ADDITIONAL CHARGES MAY APPLY UPON INVOICING

THANK YOU!
Please allow 10 business days from submission of this form for fabrication
Name*

Practitioner nameFacility
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Submission date*

MonthDayYear
Date
Requested In Office*

MonthDayYear
Date
Patient name*

First InitialLast Name
Affected Side*
Patient Weight*
Activity Level*
*NOTES* (Please indicate ALL cast modifications, alignment changes, cover measurements, special instructions)
My Products
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Lamination
$600.00 Lamination type



Transfer
Transfer alignment for two-stage laminations OR when replacing componentry

$ Free



Cast Modifications
$ Free



Volume Changes
MUST include appropriately sized ply sock with order to avoid additional $50 charge

$ Free



Suspension Install
$50.00



Flexible Interface
$ Free MaterialFinished thickness



End pad
Plastazote

$ Free Thickness



Stovepipe/SC Wedge
$ Free Material



Cut Frame/ Windows
$ Free



Boa Install
$ Free



Lamination Finish
$ Free Color



Cosmetic Cover
Sink and shape *Please include measurements in Notes*

$ Free Material



Laminated Cosmetic Shell/C-Leg Cover
$ Free



Total

$0.00
Should be Empty:

Please allow 10 business days from submission of this form for fabrication