Transfemoral Prosthetic Order Form

8647 W. 95th Street • Hickory Hills, IL 60457 • ( T ) 866.914.AOPS • ( T ) 708.237.4099 • ( F) 708.598.2857

(2677)

PA T I E N T I N F OR MAT I ON

Patient Name: Today’s Date: Due Date:

Patient ID #: Account #: P.O. #:

Sex: ■ M ■ F Affected Side: ■ Left ■ Right ■ Bilateral Facility: Practitioner:

Age: Color: Bill To: Ship To:

Weight: MT P :

Activity Level: ■ Low ■ Moderate ■ High ■ Very High ■ Ground ■ 2 Day ■ Next Day

O R D E R D E TA I L S

1 Procedure: ■ N/A 3 Knee: ■ N/A 6 Suspension: ■ N/A

■ Test Socket ■ Transfer Single Axis: ■ Shuttle Lock

■ Permanent Socket ■ Finish ■ Safety ■ Hydraulic Type:
■ Pneumatic ■ Locking Part #:
■ Vivak ■ 1/8
■ HD Hip Joint:
■ Surylan ■ 3/16 ■ Suction Valve
■ CoPoly ■ 1/4 Multi-Axis: Type:
■ Hydraulic ■ Pneumatic Part #:
■ Blister ■ Drape
Type:
Part #: ■ Clutch Lock ■ Pull Strap
2 Design: ■ N/A
■ Selesian ■ Harmony
■ Endoskeletal ■ Exoskeletal 4 Socket: ■ N/A ■ Pelvic Belt
■ Hip Joint:
■ Shoe with Px ■ No Shoe ■ Polyester ■ Carbon
Heel Height: ■ Epoxy ■ Fiberglass 7 Cover: ■ N/A
Foot Size: ■ Acrylic
Part #: ■ Bock Soft ■ Bock Firm
Carbon Frame: ■ OWW ■ PE Shell
Componentry: ■ Temporary ■ Heavy ■ 3/16 ■ Other:
■ Definitive ■ Light ■ 1/4
■ Sink
Pylon Material: ■ Aluminum ■ Copoly ■ Rough Shape (1" Over)
■ Titanium ■ Steel ■ Proflex ■ Shape to Tracing
Pylon Diameter: ■ 22mm ■ Shape to Measurements
■ 30mm ■ 34mm
Socket Attachment: ■ 3 Strap
■ 5R1 ■ Receiver
■ Pyramid ■ Rotatable

ADDI TI ONAL INSTRUCTIONS / ITEMS TO ORDER

2014.11_1.1