Transfemoral Check Socket Order Form 5.3

Transfemoral Check Socket Order Form v5.3

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 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

Cancelof
If a Discrepancy Exists, Go By*

ImpressionMeasurements
Units of Measure*

CentimetersMillimeters
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 CastAlignment Lines on Cast/Impression
Trimlines

AOPS TrimlinesCustomer TrimlinesTrimlines Drawn on Cast
Additional Instructions