Transfemoral Order Form 5.3

Transfemoral Order Form v5.3

Standard Fabrication 7 Business Days
- Facility
- PO # (Encounter #)
- Transaction # (PCC#)
- Shipping Method
- Practitioner
- Practitioner Email
  Johnsmith@example.com
- Billing Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Shipping Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Today's Date
  
  MonthDayYear
- Requested Due Date
  
  MonthDayYear
- First Initial & Last Name
- CRM #
- Activity Level
- Affected Side
- Sex
- Height
- Weight
- Submitted Model
- Procedures
  
  Other
- More Procedures
  
  Other
- Check Socket Plastic
  
  Other
- Vacuum Forming Method
- Check Socket Plastic Thickness
  
  Other
- Flexible Inner Plastic
  
  Other
- Vacuum Forming Method
- Flexible Inner Plastic Thickness
  
  Other
- Posterior Dacron Strap
- Strap Thickness
  
  Other
- Strap Color
  
  Other
- Custom Insert Material
  
  Other
- Insert Color
- Insert Thickness
  
  Other
- Add Ons
  
  Other
- End Pad Material
  
  Other
- End Pad Thickness
  
  Other
- Removable End Pad
- Shuttle Lock
  
  Other
- Suction Valve
  
  Other
- Elevated Vacuum
  
  Other
- Lanyard
  
  Other
- Suspension
  
  Other
- Support Structure
- Componentry
- Component Material
- Pylon Diameter
- Knee Type
- Foot Type
- Other Components
- Attachment Shape
- Attachment Rotation
- Resin
  
  Other
- Ultralight Weight Design
- AOPS Recommended Layup
- Describe Your Custom Layup In Detail
- Lamination Color
  
  Other
- Frame Options
  
  Other
- Cover
  
  Other
- Fairing
  
  Other
- Cover Process
  
  Other
- Cover Finish
  
  Other
- Calf Circumference
- Ankle Circumference
- Additional Instructions
- Billing Codes
- Should be Empty:

Transfemoral Order Form v5.3