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Spinal Order Form

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1. Jacket Type

N/A

Closure: LSO CTLSO TLSO	Anterior Open Posterior Open Bivalve interlock Bivalve sliding	Correction: Yes No	Openings: Chest Breast Feeding tube

Specify:		Lordosis:

N/A

Polypro Polyeth Copoly LLDPE (modpe)	Thickness: 1/8" 5/32" 3/16" 1/4"	Lining: Yes No	Lining: Yes No
Polypro Polyeth Copoly LLDPE (modpe)	Thickness: 1/8" 5/32" 3/16" 1/4"	Thickness and material:	Thickness and material:

Tongue: Yes No	Bivalve:	Anterior	Posterior
Thickness and material:		Thickness and material:	Thickness and material:

Color: Natural (white) Other If other, please specify:	Straps: Select One: Dacron backed Leather backed Select One: Attached Unattached	Strap color:	Strap size: 1" 1.5" 2"
Color: Natural (white) Other If other, please specify:		Ribbon #:	Strap size: 1" 1.5" 2"

Ventilate: Yes No		Scoli Options:
Describe:		Lyon Milwaukee Rosenberg Wilmington

Return cast: Yes No	X-rays sent: Yes No

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