UCB Order Form 5.2

UCB Order Form v5.2

Standard UCB Fabrication 4 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
First Initial & Last Name
CRM #
Affected Side *
Cast Type *

Device
Device *

UCB
Modification *

Standard Minimal
Standard Modifications Include:
- Square and leveled plantar surface - Calcaneal roundness is maintained
- 3 mm (1/8") build-up to navicular and calcaneal tuberosity
- Arches at plantar surface are not modified
- 3 mm build-up added to marked bony areas
Minimal Modifications Include:
- Square and leveled plantar surface - Calcaneal roundness is maintained
- 3 mm (1/8") build-up to navicular and calcaneal tuberosity
- Plantar surface of cast modified to ~1/4" depth
- 3 mm build-up added to marked bony areas

Additional Instructions
Guidelines

Return Cast Trimlines Drawn on Cast Trimlines Provided as a Sketch
Additional Instructions

Anatomical Measurements
If a Discrepancy Exists, Go By *

Impression Measurements
Units of Measure *

Centimeters Millimeters
Metatarsal ML *
Length of Foot *
Footplate Length *