Spinal Orthosis Order Form 5.3

Spinal Orthosis Order Form 5.3

Standard Fabrication 6 Business Days

Account Information
Facility*
PO # (Encounter #)*
Transaction # (PCC #)*
Shipping Method*
Practitioner*
Practitioner Email*
example@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

Device
Cast Type*
Spinal Orthosis Type*

LSOSoft TLSO with External FrameTLSOScoliosis TLSOOther
Scoliosis Options*

Plastic Hinged LyonRosenbergerWilmingtonOther
All TLSO's will require the following measurements:
- Xiphoid circumference, ML, and AP
- Waist circumference, ML, and AP
- Trochanter circumference, ML, and AP
- Waist to sternal notch
- Waist to scapular spine
- Waist to axilla length
- Waist to xiphoid length
- Waist to ASIS length
- Waist to symphysis pubis length
- Waist to trochanter length
Additional measurements are considered supplementary
The standard AOPS Soft TLSO with External Frame will include the following:
- 5 mm (3/16") Aliplast Internal Lining
- 3 mm (1/8") Aliplast 10 External Lining
- 3 mm Copolymer Frame
- Abdominal and Spinous Process Openings
- 6 Chafes and Dacron Straps
The following measurements are required:
- Xiphoid circumference, ML, and AP
- Waist circumference, ML, and AP
- Trochanter circumference, ML, and AP
- Waist to sternal notch length
- Waist to scapular spine length
- Waist to axilla length
- Waist to xiphoid length
- Waist to ASIS length
- Waist to symphysis pubis length
- Waist to trochanter length
Additional measurements are considered supplementary
All LSO's will require the following measurements:
- Xiphoid circumference, ML, and AP
- Waist circumference, ML, and AP
- Trochanter circumference, ML, and AP
- Waist to inferior angle of scapula length
- Waist to xiphoid length
- Waist to ASIS length
- Waist to symphysis pubis length
- Waist to trochanter length
Additional measurements are considered supplementary
The standard AOPS Rosenberger includes:
- 4 mm (5/32") Modified Polyethylene Construction
- Anterior Opening
- 5 mm (3/16") Aliplast Lining
- 2.5 mm (3/32") Modified Polyethylene Tongue
- Polyethylene Stem and Keeper Closure
- 3, 38 mm (1.5") Chafes and Dacron Straps
- 13 mm (1/2") Pelite Thoracic Pad with Dacron Sling
- 13 mm Pelite Lumbar Pad with Dacron Sling
The Rosenberger requires the following measurements:
- Xiphoid circumfernce, ML, and AP
- Waist circumference, ML, and AP
- Trochanter circumference, ML, and AP
- Waist to axilla length
- Waist to xiphoid length
- Waist to ASIS length
- Waist to symphysis pubis length
- Waist to trochanter length
Additional measurements are considered supplementary

Additional Instructions
Guidelines

Return CastTrimlines Drawn on CastTimlines Provided as a Sketch
Additional Instructions

Anatomical Measurements
If a Discrepancy Exists, Go By*

ImpressionMeasurements
Units of Measure*

CentimetersMillimeters
Show Additional Measurements

YesNo
Axilla Circumference*
Axilla ML*
Axilla AP*
Xiphoid Circumference*
Xiphoid ML*
Xiphoid AP*
Waist Circumference*
Waist ML*
Waist AP*
Trochanter Circumference*
Trochanter ML*
Trochanter AP*
Waist to Trochanter*
Waist to Symphysis Pubis*
Waist to ASIS*
Waist to Xiphoid*
Waist to Inf. Angle of Scapula*
Waist to Axilla*
Waist to Scapular Spine*
Waist to Sternal Notch*
Nipple Line Circumference
Nipple Line ML
Lower Rib Circumference
Lower Rib ML
Waist to Gluteal Fold
Waist to Nipple Line
Please Provide Additional Anatomical Measurements Relevant to Design