Cosmetic Cover Order Form Cosmetic Cover Order Form GENERAL Clinic/Hospital Name: Provider Name: Shipping Address: City: State: Zip Code: Phone Number: Billing Point of Contact: Billing Contact Email: PO#:(optional) Email: Please check the box if billing address is same as shipping address. Billing Address: City: State: Zip Code: PATIENT First Name: Last Name: Birthday: Weight (lbs): Gender: MaleFemale Activity Level: K1K2K3K4 SCANNER Scanner: StructureArtecOther Scanner App: DigiScan3D3DSizeMeOther Email scan of definitive leg, and contralateral limb if applicable to to scans@protosthetics.com FOOT Foot: Foot Shell: Foot Shell Size: DESIGN OPTIONS Design: Printed SolidPrinted VoronoiGraphic Lamination Print Color (if solid or voronoi): WhiteBlackBlueClearGreenOrangeRed Lamination (if applicable): NoneProtosthetics Provides PatternClinic Provides Pattern COVER TYPE Amputation Level: BKAKBEAE Amputation Side:LeftRight Style: ContralateralC-Leg TypeParametric Model from Measurment (Amphibian) ADDITIONAL COMMENTS Additional Comments: