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:

    Amputation Side:LeftRight

    Amputation Level: BKAK - Coming Soon

    Lead Time

    Lead Time:

    Free 3D Printed Check Socket:Yes(May add lead time)Skip

    Scanner

    3D Scans or Ship us an Aligned Check Socket: ScanCheck Socket

    Scanner:

    Scanner App:

    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:

    T-Shirt Lamination (Additional Cost)

    AquaPaw Color:

    AquaPaw - 3/8" Heel Lift: YesNo

    PTB to Floor Measurement (cm):

    ADDITIONAL COMMENTS

    Additional Comments: