CAD-CAM Order Form
Email to: ORDERS@GPFINC.COM Fax to: 727-842-2264
Sent to:
orders@gpfinc.com
Today's Date
-
Month
-
Day
Year
Today's Date
Request by Date
-
Month
-
Day
Year
Request By Date
Practitioner's Name
Practitioner Phone Number
Please enter best phone number to reach you at.
Format: (000) 000-0000.
Contact Email
Clinic Name:
Ship to Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
UPS or FEDEX
Please Select
UPS
FEDEX
Select UPS or FedEx for your Carrier - if you do not have an account we will use our UPS Account
Your Account #
Please enter your UPS/FedEx Account Number
Select Service
Please Select
Ground
3-Day
2-Day
2-Day AM
Next Day
Next Day Saver
Next Day AM
Please select shipping service
PO#
Please enter PO#
Patient's Name
Patient Age
Weight
Height
Male/Female
Left/Right/Bilateral
Please Select
Left
Right
Bilateral
**FOR BILATERAL PLEASE FILL OUT ONE FORM FOR EACH SIDE**
Socket Type
AK
BK
CAD-CAM Type
Test Socket
Carving Only
Material Requested for Test Socket
Please Select
PETG
Thermolyn
Polypro
Measurements Taken Over Liner?
Yes
No
If "Yes" please indicate amount to be reduced by below
Ischium to Distal End Measurement
Perineum to Distal End Measurement
Distal End Attachment Type
Grace Plate - "Please List"
Pyramid - "Please List"
Wood Block
Space - "Please List"
Valve - "Please List"
Other - "Please List"
None
"Please List" Distal End Attachment Type
Residual Limb Measurement
Brim Style
NML
SNML
Aggressive
Quad-Standard
Other - Please List
If "Other" Brim Style - Please List
Measurements
Please enter each measurement below
0
2
4
6
8
10
12
14
Special Instructions/Additional Notes
Upload any reference images or documents
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: