Transtibial Check Socket Order Form 5.2

Transtibial Check Socket Order Form v 5.2

Standard Fabrication 1-3 Business Days

Account Information
HFN Chicago E2 Job#
HFN Chicago Raven Job#
Priority: Morning Courier Standard Courier FedEx Ground

	Scan/Cast	Mod	VF	CBT	Finish
Input Grade
Initials

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 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 order@aopsolutions.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

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

Impression Measurements
Units of Measure *

Centimeters Millimeters
PML
ML
AP
MPT to Distal End
MPT to Distal End of Tibia

	Residual Limb Circumferences
0 (MPT Level)
1" (25 mm)
2" (51 mm)
3" (76 mm)
4" (102 mm)
5" (127 mm)
6" (152 mm)
7" (178 mm)
8" (203 mm)
9" (229 mm)
10" (254 mm)
11" (279 mm)

Finishing
Guidelines

Return Cast Trimlines Drawn on Cast
Trimlines

AOPS Trimlines Customer Trimlines Trimlines Drawn on Cast
Posterior Shelf Shape

W-Shape Angled Straight
Anterior Trim Height
Medial/Lateral Trim Height
Posterior Shelf Location