Upload a Scan

Upload a Scan

GENERAL

Clinic/Hospital Name:

Provider Name:

Shipping Address:

City:

State:

Zip Code:

Phone Number:

PO#:(optional)

Email:



Please check the box if billing address is same as shipping address.

Billing Address:

City:

State:

Zip Code:

PATIENT

Patient ID:

Activity Level:

Patient Weight:

Upload File:

Amputation Level:

AKBKAEBE

Amputation Side:

LeftRight

Additional Comments:

DESIGN

PETG Solid

Modifications

PETG Diamond

Volumetric Reduction: %

ADDITIONS

4-Hole Adapter(Add $$)

Vacuum Hole

Terms + Conditions