Amphibian Order Form Amphibian 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 Amputation Side:LeftRight Amputation Level: BKAK - Coming Soon Lead Time Lead Time:10-14 Day (Free)Expedited (Please call) Free 3D Printed Check Socket:Yes(May add lead time)Skip Scanner 3D Scans or Ship us an Aligned Check Socket: ScanCheck Socket Scanner: StructureArtecOtherNo Scan Scanner App: DigiScan3D3DSizeMeOtherNo Scan Scanned Medium: Must scan the inside of the definitive socket and outside of the entire primary prosthesis Email inside, outside, and any other scans to scans@protosthetics.com DESIGN OPTIONS Color: BlackWhiteCaucasian T-Shirt Lamination (Additional Cost) AquaPaw Color: BlackBlue AquaPaw - 3/8" Heel Lift: YesNo PTB to Floor Measurement (cm): ADDITIONAL COMMENTS Additional Comments: