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Transfemoral Prosthetic Order Form

PATIENT INFORMATION:
* = Required
Patient's Name:*		Sex: Male Female	Affected Side:* Left Right Bilateral
Patient ID#		Age:	Color:
Weight:	MTP:	Activity Level: Low Moderate High Very High
Today's Date:		Due Date:
Account #		P.O. #
Facility: *		Practitioner:*
Bill to:*
Ship to:*
	Ground 2 Day Next Day

ORDER DETAILS:

	1. PROCEDURE					N/A
	Test Socket Permanent Socket	Transfer Finish	Vivak Surylan CoPoly	1/8 3/16 1/4	Blister Drape
	2. DESIGN					N/A
	Endoskeletal Exoskeletal	No Shoe Shoe with Px Heel Height: Foot Size: Part #:	Componentry: Temporary Definitive	Pylon Material: Titanium Aluminum Steel	Pylon Diameter: 22mm 30mm 34mm	Socket Attachment: 5R1 Pyramid 3 Strap Receiver Rotatable
	3. KNEE					N/A
	Single Axis: Safety Pneumatic Hydraulic Locking HD Hip Joint:	Multi-Axis: Hydraulic Pneumatic Type: Part #:
	4. SOCKET					N/A
	Polyester Epoxy Acrylic Carbon Fiberglass	Carbon Frame: Heavy: 3/16 1/4 Light: 3/16 1/4	Copoly Proflex
	5. SUSPENSION:					N/A
	Clutch Lock Selesian Pelvic Belt Harmony Pull Strap Hip Joint:	Shuttle Lock: Type: Part #:	Suction Valve: Type: Part #:
	6. COVER:					N/A
	Bock Soft OWW Bock Firm PE Shell Other:	Sink Rough Shape (1" Over) Shape to Tracing Shape to Measurements
ADDITIONAL INSTRUCTIONS / ITEMS TO ORDER:

1. PROCEDURE