• Spinal Orthosis Order Form 5.3

    Spinal Orthosis Order Form 5.3

    Standard Fabrication 6 Business Days
    • Account Information 
    • Order Information 
    • Today's Date
       - -
    • Requested Due Date*
       - -
    • Is This Device of Urgent Nature*
    • Date / Time Needed in Office*
       - - :
    • May we proceed with fabrication or is the Job on HOLD?
    • Have X-Rays Been Sent*
    • X-Ray Delivery Method*
    • Device 
    • Spinal Orthosis Type*

    • Scoliosis Options*

    • Image field 97

    • All TLSO's will require the following measurements:

      • Xiphoid circumference, ML, and AP
      • Waist circumference, ML, and AP
      • Trochanter circumference, ML, and AP
      • Waist to sternal notch
      • Waist to scapular spine
      • Waist to axilla length
      • Waist to xiphoid length
      • Waist to ASIS length
      • Waist to symphysis pubis length
      • Waist to trochanter length

      Additional measurements are considered supplementary

    • Image field 104

    • The standard AOPS Soft TLSO with External Frame will include the following:

      • 5 mm (3/16") Aliplast Internal Lining
      • 3 mm (1/8") Aliplast 10 External Lining
      • 3 mm Copolymer Frame
      • Abdominal and Spinous Process Openings
      • 6 Chafes and Dacron Straps

      The following measurements are required:

      • Xiphoid circumference, ML, and AP
      • Waist circumference, ML, and AP
      • Trochanter circumference, ML, and AP
      • Waist to sternal notch length
      • Waist to scapular spine length
      • Waist to axilla length
      • Waist to xiphoid length
      • Waist to ASIS length
      • Waist to symphysis pubis length
      • Waist to trochanter length

      Additional measurements are considered supplementary

    • Image field 98

    • All LSO's will require the following measurements:

      • Xiphoid circumference, ML, and AP
      • Waist circumference, ML, and AP
      • Trochanter circumference, ML, and AP
      • Waist to inferior angle of scapula length
      • Waist to xiphoid length
      • Waist to ASIS length
      • Waist to symphysis pubis length
      • Waist to trochanter length

      Additional measurements are considered supplementary

    • Image field 99

    • The standard AOPS Rosenberger includes:

      • 4 mm (5/32") Modified Polyethylene Construction
      • Anterior Opening
      • 5 mm (3/16") Aliplast Lining
      • 2.5 mm (3/32") Modified Polyethylene Tongue
      • Polyethylene Stem and Keeper Closure
      • 3, 38 mm (1.5") Chafes and Dacron Straps
      • 13 mm (1/2") Pelite Thoracic Pad with Dacron Sling
      • 13 mm Pelite Lumbar Pad with Dacron Sling

      The Rosenberger requires the following measurements:

      • Xiphoid circumfernce, ML, and AP
      • Waist circumference, ML, and AP
      • Trochanter circumference, ML, and AP
      • Waist to axilla length
      • Waist to xiphoid length
      • Waist to ASIS length
      • Waist to symphysis pubis length
      • Waist to trochanter length

      Additional measurements are considered supplementary

    • Design 

    • Lordosis*

    • Opening*
    • Cut Outs

    • Foam In Waist Area*
    • Tongue*
    • Ventilation Holes*
    • Scoliosis Modification & Padding Options 
    • Axillary Extension
    • Thoracic Sling
    • Lumbar Pad
    • Trochanteric Pad
    • Trochanteric Extension
    • Lumbar Pad Design*
    • Thermoforming 
    • Plastic Type*

    • Plastic Frame Type*

    • Plastic Thickness*


    • Lining*
    • Lining Thickness*


    • Finishing 
    • Strap Material*
    • Strap Color*
    • Strap Size*
    • Strap Attachment*
    • Rosenberg Closures*

    • Additional Instructions 
    • Guidelines
    • Anatomical Measurements 
    • If a Discrepancy Exists, Go By*
    • Units of Measure*
    • Show Additional Measurements
    • AOPS Billing 
    • Should be Empty: