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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Submitted Model
Free



Lamination
When ordering products OTHER THAN LAMINATED SOCKETS, please choose "Accessory Fab". Options for these products are included elsewhere on this form

$660.00 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



Add Strapping
ANY straps, INCLUDING posterior frame control strap

Free



Total

$0.00
Should be Empty:

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

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

My Products