Gavin Scoliosis Project (GSP) Order Form 5.2

(GSP) Order Form v5.2

Standard Fabrication 6 Business Days

Account Information
Interested in using the GSP in your practice? Click the AOPS logo below to learn more!
Are You GSP Certified? *

Yes No
Certification #
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 #
Sex
Height
Weight

Device
For a King 5 Classification, please contact our scoliosis expert, Thomas Gavin, LCO

Telephone: (630) 936-0731

Email: TomGavin@me.com
Cast Type *
King Classification *

King 1 King 2 King 3 King 4
The GSP requires the following:
- King Classification
- Color of Plastic and Straps
- Transfer Description
- Measurements
The King 1 GSP Orthosis Contains the Following:
- Anterior Opening
- 4 mm (5/32") Modified Polyethylene (MPE) Construction
- 5 mm (3/16") Aliplast Lining
- 2 mm (3/32") MPE Tongue
- 2, 50 mm (2") Anterior Dacron Straps
- 178 (7") mm x 25 mm (1") x 3 mm (1/8"), Polyethylene Billet
- Polylethylene Keeper
- Axillary Extension
- Pelite Lumbar Pad with Internal Washers and Dacron Sling
- Built-in Brace Lumbar Modification
- Built-in Brace Medius Modification
The Following Measurements are required:
- Axilla circumference, ML, and AP
- Xiphoid circumference, ML, and AP
- Waist circumference, ML, and AP
- ASIS 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 *
- Symphysis pubis to sternal notch length *
All length measurements should be taken supine, topographically
The King 2 GSP Orthosis Contains the Following:
- Anterior Opening
- 4 mm (5/32”) Modified Polyethylene (MPE) Construction
- 5 mm (3/16") Aliplast Lining
- 2 mm (3/32”) MPE Tongue
- 2, 50 mm (2") Anterior Dacron Straps
- 178 mm (7") x 25 mm (1") x 3 mm (1/8"), Polyethylene Billet
- Polyethylene Keeper
- Polyethylene Bridge
- Axillary Extension
- Pelite Lumbar Pad with Internal Washers and Dacron Sling
- Pelite Thoracic Pad with Internal Washers and Dacron Sling
- Built-in Brace Lumbar Modification
- Built-in Brace Medius Modification
The Following Measurements are required:
- Axilla circumference, ML, and AP
- Xiphoid circumference, ML, and AP
- Waist circumference, ML, and AP
- ASIS circumference, ML, and AP
- Trochanter circumference, ML, and AP
- Waist to superior angle of scapula length *
- Waist to axilla length *
- Waist to xiphoid length *
- Waist to ASIS length *
- Waist to symphysis pubis length *
- Waist to trochanter length *
- Symphysis pubis to sternal notch length *
All length measurements should be taken supine, topographically
The King 3 GSP Orthosis Contains the Following:
- Anterior Opening
- 4 mm (5/32”) Modified Polyethylene (MPE) Construction
- 5 mm (3/16") Aliplast Lining
- 2 mm (3/32”) MPE Tongue
- 2, 50 mm (2") anterior Dacron straps
- 178 (7") mm x 25 mm (1") x 3 mm (1/8"), Polyethylene Billet
- Polyethylene Keeper
- Polyethylene Bridge
- Axillary Extension
- Pelite Thoracic Pad with Internal Washer and Dacron Sling
- Built-in Lumbar modification
- Built-in Medius modification
The Following Measurements are required:
- Axilla circumference, ML, and AP
- Xiphoid circumference, ML, and AP
- Waist circumference, ML, and AP
- ASIS circumference, ML, and AP
- Trochanter circumference, ML, and AP
- Waist to superior angle of scapula length *
- Waist to axilla length *
- Waist to xiphoid length *
- Waist to ASIS length *
- Waist to symphysis pubis length *
- Waist to trochanter length *
- Symphysis pubis to sternal notch length *
All length measurements should be taken supine, topographically
The King 4 GSP Orthosis Contains the Following:
- Anterior Opening
- 4 mm (5/32”) Modified Polyethylene (MPE) Construction
- 5 mm (3/16") Aliplast Lining
- 2 mm (3/32”) MPE Tongue
- 2, 50 mm Anterior Dacron Straps
- 178 (7") mm x 25 mm (1") x 3 mm (1/8"), Polyethylene Billet
- Polyethylene Keeper
- Polyethylene Bridge
- Axillary Extension
- Pelite Thoracic Pad with Internal Washers and Dacron Sling
- Pelite Lumbar Pad with Internal Washers and Dacron Sling
- Built-in Brace Lumbar modification
- Built-in Brace Medius modification
The Following Measurements are required:
- Axilla circumference, ML, and AP
- Xiphoid circumference, ML, and AP
- Waist circumference, ML, and AP
- ASIS 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 *
- Symphysis pubis to sternal notch length *
All length measurements should be taken supine, topographically

Thermoforming
Plastic Type *

Modified Polyethylene (MPE)
Plastic Thickness *

4 mm (5/32")
Color *

White (Standard)
Transfer Description

Additional Information
Additional Instructions

Anatomical Measurements
If a Discrepancy Exists, Go By *

Impression Measurements
Units of Measure *

Centimeters Millimeters
Show Additional Measurements

Yes No
Axilla Circumference *
Axilla ML *
Axilla AP *
Xiphoid Circumference *
Xiphoid ML *
Xiphoid AP *
Waist Circumference *
Waist ML *
Waist AP *
ASIS Circumference *
ASIS ML *
ASIS AP *
Trochanter Circumference *
Trochanter ML *
Trochanter AP *
Waist to Trochanter *
Waist to Symphysis Pubis *
Waist to ASIS *
Waist to Xiphoid *
Waist to Axilla *
Waist to Sup. Angle of Scapula
Distance Between ASIS
Symphysis Pubis to Sternal Notch
Lower Rib ML
Lower Rib Circumference
Sternal Notch AP
Waist to Sternal Notch
Waist to Nipple Line
Waist to Inf. Angle of Scapula
Waist to Coccyx
Waist to Gluteal Fold

(GSP) Order Form v5.2