Purchase High-Quality Prosthetic and Orthotic Products Patient Name(Required) PT.WT*(Required) PO#(Required) Practitioner(Required) Date(Required) MM slash DD slash YYYY Due by(Required) MM slash DD slash YYYY Checkbox(Required) R L M F AK BK AE BE SYMES CHOPART PREPFINISH RUSH Activity Level(Required)LowModerateHighLamination Instructions Dropdown(Required)EXOENDOMODIFYCASTREDUCE ENLARGEBY(Required) Suspension(Required)SleeveCuff StrapSupra CondylarSalesian Hip JointLanyardValveShuttle lockLiner(Required)BockliteOP-flexPolyethyleneProflexProflex w/SiliconeGano Brim TThicknessOtherColor Choice(Required) No color Asian Caucasian Negroid Latin Color Lay Up(Required)No DacronFull DacronDacronI-Beam:Full Carbon/ Separation LayersNylonNyglass/Full CarbonExtra CarbonFinish Nylon- (1 Nylon) (2 Nylon)Circumference(Required)No CoverSilhouette DrawingKnee CenterAnkle(Required)CalfKneeThigh DistalThigh ProximalComments(Required)Bill to(Required) Ship to(Required)
