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:

    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)

    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:

    AK Socket Shape Diagrams

    Suspension

    Distal Adapter:

    Component Used:

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

    Alignment

    Alignment:

    Degrees Abduction:

    Degrees Adduction:

    Degrees Flexion:

    Degrees Extension:

    ADDITIONAL COMMENTS

    Additional Comments: