Miscellaneous Orthosis / Prosthesis Order Form v5.2
Fabrication Time Will Vary Based on Design
Account Information
Facility
*
PO # (Encounter #)
*
Transaction # (pCC#)
*
Shipping Method
*
Courier
Ground
2 Day
Next Day Air
Next Day Saver
Practitioner
*
Practitioner Email
*
Johnsmith@example.com
Same Billing/Shipping Address
Billing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Shipping Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Order Information
Today's Date
-
Month
-
Day
Year
Date Picker Icon
Requested Due Date
*
-
Month
-
Day
Year
Date Picker Icon
First Inital & Last Name
*
CRM #
Activity Level
Low (K1)
Moderate (K2)
Average (K3)
High (K4)
Affected Side
Left
Right
Bilateral
Sex
Male
Female
Height
Weight
Device
Please Provide a Description of the Type of Device
Design
Please Provide a Detailed Description of the Device's Design (trimlines, windows, etc.)
Thermoforming
Please Provide a Detailed Description on the Device's Thermoforming Process (type of plastic, thickness, color, etc.)
Finishing
Please Provide a Detailed Description on the Finishing (straps, padding, etc.) Necessary for This Design
Additional Instructions
Please Provide Any Additional Information Not Covered in the Previous Sections
Anatomical Measurement
Please Provide Any Anatomical Measurements Necessary for the Design and the Units of Measure Used
Submit
Should be Empty: