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Pectus Carinatum Brace Form

    ORDER INFORMATION

    Order Date:

    Lead Time:

    Date Needed (additional charges may apply):

    PO#:

     

    SHIPPING INFORMATION

    Facility:

    Practitioner:

    Address:

    City:

    State:

    Zip Code:

    Phone:

    Email:

    BILLING INFORMATION

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

    Facility:

    Practitioner:

    Address:

    City:

    State:

    Zip Code:

    Phone:

    Email:

    SHIPPING INSTRUCTIONS

    Ground2-day (additional charges)Overnight (additional charges)Local

    PATIENT INFORMATION

    Name:

    Sex:

    DOB:

    Height of Deformity:

    (cm)

    Width of Deformity:

    (cm)

    Diagnosis/Special Instructions:
    Have a Tech Call Me

     

    SCANNER

    Scanner:

    Other:

    Scanner App:

    Other:

    Please email scans to scans@protosthetics.com

    DESIGN OPTIONS

    Panel Color:

    Anterior/Posterior Panel Foam:

    Add Anterior Gel Pad (+$25):

    Add iButton (+$135):

    Side Panel Foam:

    Aluminum Bar:

    Please send screenshots of panel layout before printing:

    ADDITIONAL COMMENTS

    Additional Comments: