Toll Free: 866.914.AOPS

Transtibial 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 Surlyn 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. INSERT					N/A
	BockLite 3mm BockLite 6mm PeLite 1/8 PeLite 3/16
	4. END PAD					N/A
	Plastizote Aliplast Other:	1/8 1/4 3/16 1/2	Add-Ons: Stove Pipe Pull Straps
	5. SOCKET					N/A
	Polyester Epoxy Acrylic Carbon Fiberglass	Layup: 1 2 3 4	Carbon Frame CoPoly Flexible Inner Socket
	6. SUSPENSION:					N/A
	SPSC Sleeve SC Harmony	Shuttle Lock: Type: Part #:	Suction Valve: Type: Part #:		Cuff Waist Belt Pull Hole Fork Strap Joint/Corset	Door Opening: Medial Posterior
	7. 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