Transfemoral Check Socket Order Form 5.2

Transfemoral Check Socket Order Form v5.2

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

City State / Province

Postal / Zip Code Country
Shipping Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Order Information
Today's Date

Month Day Year
Requested Due Date *

Month Day Year
May we proceed with 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 order@aopsolutions.com when it is ok to proceed.
First Initial & Last Name
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)
Template/Brim Reference Shape
3D Scan for Socket

Browse Files

Cancel of
If a Discrepancy Exists, Go By *

Impression Measurements
Units of Measure *

Centimeters Millimeters
Lateral AP
Medial AP
Skeletal ML
Soft ML
IT to Distal End
IT to Floor
IT to Distal End of Femur
Knee Center to Floor

	Residual Limb Circumcferences
0 (IT Level)
1" (25.4 mm)
2" (50.8 mm)
3" (76.2mm)
4" (101.6 mm)
5" (127 mm)
6 " (152.4 mm)
7" (177.8 mm)
8" (203.2 mm)
9" (228.6 mm)
10" (254 mm)
11" (279.4 mm)
12" (304.8 mm)
13" (330.2 mm)
14" (355.6 mm)
15" (381 mm)
16" (406.4 mm)
17" (431.8 mm)
18" (457.2 mm)

Finishing
Guidelines

Return Cast Alignment Lines on Cast/Impression
Trimlines

AOPS Trimlines Customer Trimlines Trimlines Drawn on Cast
Additional Instructions