Transtibial Order Form

Facility Name* This field is required.

Practitioner* This field is required.

Today's Date* This field is required.

Date

Requested Due Date* This field is required.

Date

Billing Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Shipping Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Affected Side* This field is required.

Left

Right

Activity Level* This field is required.

Weight* This field is required.

lbs

Submitted Model* This field is required.

Plaster Positive

Negative

Digital scan

Measurements

Tracings

Desired Procedures* This field is required.Check ALL that apply

Diagnostic socket (Printed)

Flexible inner liner (printed)

Diagnostic socket (thermoformed)

Flexible inner liner (Thermoformed)

1st lamination ONLY

Complete lamination

Add pull straps

Custom finish lamination

Custom cosmetic cover

Socket ONLY

Set up on componentry

Other

Alignment* This field is required.

Transfer

Bench Alignment

Alignment Lines on Model

N/A

Suspension type* This field is required.Please select ONE

Shuttle lock (NEW)

Shuttle lock (REUSE)

Elevated vacuum (NEW valve)

Elevated vacuum (REUSE valve)

Passive suction (NEW valve)

Passive suction (REUSE valve)

SPSC w/medial wedge

Thigh cuff

Joint & corset

Other

N/A

Vacuum forming* This field is required.Check all that apply. Also choose from appropriate 3D printed otions

Drape

Blister

Standard Vivak

Proflex inner liner (3/16")

Thermolyn

Proflex inner liner (1/4")

Mediflex

Orfitrans

Northvane (CLEAR)

Northvane (BLACK)

N/A

Other

Custom insert* This field is required.Check ALL that apply

Bocklite

Pelite

Keasy cone

Plastazote end pad (1/2")

N/A

Other

Componentry* This field is required.Check ALL that apply. Socket attachments must ALWAYS be new

Endoskeletal

Exoskeletal

Reuse temporary

Definitive

Use provided definitive

30mm

34mm

Titanium

Aluminum

Male pyramid

Female receiver

3-strap

4-hole plate

Rotatable attachment

Other

Color* This field is required.*Please specify carbon finish, PRS color, or pattern type

Frame options* This field is required.Check ALL that apply

Trimlines provided on cast/check socket

1cm below flexible liner

Trim flexible liner to trimlines

Leave liner long, practitioner will trim

N/A

Other

Material* This field is required.

Bock firm

Fillauer white

3D Printed

Ohio Willow Wood light

Rigid foam exo-style

Ohio Willow Wood dark

Shape to:* This field is required.Check ALL that apply

Measuremaents

Tracings

Match sides

Photos

Scan/fit to socket

Other

Measurements* This field is required.Please provide ankle and calf apex circumferences and AP/ML dimensions

Cover finish* This field is required.Check ALL that apply

Apply nylons

Apply skin

Laminated shell

Match socket color

Custom pattern

Split cover w/velcro

Split cover NO velcro

3D Printed

Special instructionsPlease provide ALL special instructions including alignment changes, foot/knee swaps, desired layup of=r finishing instructions

Remember to zip .stl/.obj files prior to uploading

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Remember to zip .stl/.obj files prior to uploading

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Transtibial Order Form