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: Birthday: Last Name: Weight (lbs): Patient Gender: MaleFemale Activity Level: K1K2K3K4 Amputation Side:LeftRight Amputation Level: BKAKAEBESymesKDChopart Date Needed Date Needed: SCANNER Scanner: StructureArtecOther Scanner App: DigiScan3D3DSizeMeOther Scanned Medium: Plaster CastModified Plaster PositiveUnmodified Plaster PositiveResidual LimbLinerStockinette (Specify ply in comments)Existing Socket Please email scans to scans@protosthetics.com DESIGN Socket Material: Printed Clear Copolyester SolidPrinted Clear Copolyester DiamondPulled VivakPulled Thermolyn Volumetric Reduction: % Volumetric Increase: % MEASUREMENTS BK Reference Measurements (If Applicable) MPT to Distal End: cm Circumferential at MPT: cm AK Measurements (If Applicable) IT to Distal End: 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: N/AQuadrilateral 1Quadrilateral 2Quadrilateral 3Narrow ML 1Narrow ML 2Narrow ML 3CATCAMSemi-Quad AK Socket Shape Diagrams Suspension Distal Adapter: None - Round BottomModeled Cavity - Clinic Supplies ComponentsModeled Cavity - Protosthetics Provides Components Component Used: (Bulldog, KISS, 4-Hole Adapter, etc.) Alignment Alignment: N/AMarked Alignment on Cast or ScanTransfer ExistingAbduction (Fill In Below)Adduction (Fill in Below)Flexion (Fill in Below)Extension (Fill in Below) Degrees Abduction: Degrees Adduction: Degrees Flexion: Degrees Extension: ADDITIONAL COMMENTS Additional Comments: