Thomas Orthotic and Prosthetic Central Fabrication INC.

6324 Bass Lake Road, Suite D Crystal, MN 55428

Tel: 612-730-1222

Fax: 763-951-3637

Email: thomas@topfinc.com Website: www.topfinc.com

PATIENT

 LAST

 INITIAL

BELOW THE KNEE FABRICATION AND MEASUREMENT FORM

PATIENT ID:

PATIENT:

AGE:

WEIGHT:

HEIGHT:

DATE:

PRAC:

MALE

FEMALE

LEFT

RIGHT

BIL

CAUCASIAN

LT.BROWN

MD.BROWN

DK.BROWN

DOCTOR:

CAUSE FOR AMPUTATION:

JOB TYPE: _NEW PROSTHESIS _SOCKET REPLACEMENT

SETUP

SPECIFY:

COVER

TYPE:

LIMB TRACING

IMAGE

LAYUP:

EXTRA LIGHT (FIBERGLASS)

STANDARD (2 LAYERS OF CORBON FIBER)

EXTRA STRONG (DEFINE

CURRENT COMPONENTS:

REUSE CURRENT COMPONENTS

LINER:

SIZE

FOOT:

SIZE

SUSPENSION:

KNEE:

SERIAL #

FOOT:

SIZE:

SERIAL #

SLEEVE:

SERIAL #

LlNER:

SERIAL #

PIN: LONG  REGULAR SHORT CUSTOM(_# OF RINGS)

SHEATHS

SOCKS:

WAIST BELT: