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

First Name:

Last Name:

Birthday:

Weight (lbs):

Patient Gender: MaleFemale

Activity Level:

Amputation Side:LeftRight

Amputation Level: BKAKAEBESymesOther

Lead Time

Lead Time:

SCANNER

Scanner:

Scanner App:

Scanned Medium:

Upload Scan:

DESIGN

Clear Copolyester Solid

Clear Copolyester Diamond*

*Diamond check sockets have diamond-shaped cutouts throughout the socket to be able to feel pressure points and problem areas.

Volumetric Reduction: %

ADDITIONS

4-Hole Adapter($40)

Suction Spacer Plate ($50)

Bulldog Pin/Shuttle-Lock Cavity ($25)


ADDITIONAL COMMENTS

Additional Comments: