UCB Order Form 5.3

UCB Order Form v5.3

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

CityState / Province

Postal / Zip CodeCountry
Shipping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Order Information
Today's Date

MonthDayYear
Requested Due Date*

MonthDayYear
First Initial & Last Name
CRM #
Affected Side*
Cast Type*

Device
Device*

UCBOther
Modification*

StandardMinimalOther
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 CastTrimlines Drawn on CastTrimlines Provided as a Sketch
Additional Instructions

Anatomical Measurements
If a Discrepancy Exists, Go By*

ImpressionMeasurements
Units of Measure*

CentimetersMillimeters
Metatarsal ML*
Length of Foot*
Footplate Length*