Prosthetics Order Form

    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: