Transtibial Check Socket Order Form 5.3

Transtibial Check Socket Order Form v 5.3

Standard Fabrication 1-3 Business Days

Account Information
Facility*
PO # (Encounter #)*
Transaction # (PCC#)*
Shipping Method*
Practitioner*
Practitioner Email*
Johnsmith@example.com
Same Billing/Shipping Address
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Shipping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Order Information
Today's Date

MonthDayYear
Requested Due Date*

MonthDayYear
May we proceedwith fabrication or is the Job on HOLD?

Yes, It is Ok to Proceed with fabrication of the device.Project NEWTON, proceed with fabrication of the device.No, this Job is on HOLD, I will email the Job PO# to HFN_Chicago@hanger.com when it is ok to proceed.
Name (First & Last Initials Only)
CRM #
Activity Level*
Affected Side*
Sex
Height
Weight*

Design
Submitted Model*
Socket Design*

Silicone Suction Socket (3-S)Total Surface Bearing (TSB)Elevated Vacuum (EV)Patellar Tendon Bearing (PTB)
3D Scan for Socket

Browse Files

Cancelof
Template/Reference Shape
If a Discrepancy Exists, Go By*

ImpressionMeasurements
Units of Measure*

CentimetersMillimeters
PML
ML
AP
MPT to Distal End
MPT to Distal End of Tibia

Socket
Plastic Type*

Bulldog CrystalVivak (PETG)Thermolyn (Polystyrene)CopolymerOther
Vacuum Forming Method*

BlisterDrape

Finishing
Guidelines

Return CastTrimlines Drawn on Cast
Trimlines

Hanger Fabrication Network Standard TrimlinesCustomer TrimlinesTrimlines Drawn on Cast
Posterior Shelf Shape

W-ShapeAngledStraight
Anterior Trim Height
Medial/Lateral Trim Height
Posterior Shelf Location