Upload a Scan

Upload a Scan

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):

Patient Gender: MaleFemale

Activity Level:

Amputation Side:LeftRight

Amputation Level: BKAKAEBESymesKDChopart

Date Needed

Date Needed:

SCANNER

Scanner:

Scanner App:

Scanned Medium:

Please email scans to scans@protosthetics.com

DESIGN

Socket Material:

Volumetric Reduction: %

Volumetric Increase: %

MEASUREMENTS

BK Reference Measurements (If Applicable)

MPT to Distal End:

cm

Circumferential at MPT:

cm

AK Measurements (If Applicable)

4" Above IT:

cm (Tight)

cm (Loose)

2" Above IT:

cm (Tight)

cm (Loose)

At IT:

cm (Tight)

cm (Loose)

2" Below IT:

cm (Tight)

cm (Loose)

4" Below IT:

cm (Tight)

cm (Loose)

6" Below IT:

cm (Tight)

cm (Loose)

8" Below IT:

cm (Tight)

cm (Loose)

10" Below IT:

cm (Tight)

cm (Loose)

12" Below IT:

cm (Tight)

cm (Loose)

14" Below IT:

cm (Tight)

cm (Loose)

16" Below IT:

cm (Tight)

cm (Loose)

18" Below IT:

cm (Tight)

cm (Loose)

20" Below IT:

cm (Tight)

cm (Loose)

AK Socket Shape:

AK Socket Shape Diagrams

Suspension

Distal Adapter:

Component Used:

(Bulldog, KISS, 4-Hole Adapter, etc.)

Alignment

Alignment:

Degrees Varus:

Degrees Valgus:

Degrees Flexion:

Degrees Extension:

ADDITIONAL COMMENTS

Additional Comments: