Spinal Orthosis Order Form 5.2

Spinal Orthosis Order Form 5.2

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

City State / Province

Postal / Zip Code Country
Shipping Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Device
Cast Type *
Spinal Orthosis Type *

LSO Soft TLSO with External Frame TLSO Scoliosis TLSO
Scoliosis Options *

Plastic Hinged Lyon Rosenberger Wilmington
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 Cast Trimlines Drawn on Cast Timlines Provided as a Sketch
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 *
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