Toll Free: 866.914.AOPS
Spinal Order Form
PATIENT INFORMATION:
* = Required
Patient's Name:
*
Patient ID#
Today's Date:
Due Date:
Account #
P.O. #
Facility:
*
Practitioner:
*
Bill to:
*
Ship to:
*
Sex:
Male
Female
Age:
Height:
Weight:
Is cast ready to be poured?
Yes
No
Other Info:
SPINAL ORDER DESCRIPTION:
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:
2. Materials
N/A
Polypro
Polyeth
Copoly
LLDPE (modpe)
Thickness
:
1/8"
5/32"
3/16"
1/4"
Lining
:
Yes
No
Lining
:
Yes
No
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"
Ribbon #:
Ventilate
:
Yes
No
Scoli Options:
Describe:
Lyon
Milwaukee
Rosenberg
Wilmington
ADDITIONAL INSTRUCTIONS:
Return cast:
Yes
No
X-rays sent:
Yes
No
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