Order Form Hip Disarticulation

							                         NATIONAL LAB LOCATIONS (Choose One)
                                                                                                                              Page 1 of 1
                           Orlando:    Ph 407.852.6170   |   Fx 407.852.6171      Workorder #
                           Kansas:     Ph 913.888.4200   |   Fx 913.888.4244
                           Tempe:      Ph 480.894.1755   |   Fx 480.921.9686
                           Anaheim:    Ph 714.961.2155   |   Fx 714.961.2181
                           CDC:        Ph 480.377.2226   |   Fx 480.377.2896           (FOR LAB USE ONLY)



Bill To:                                                                   Patient Name:
Address:                                                                                                                         Activity Level
                                                                           Height:                     Weight:        Age:               K-1
                                                                                                                                         K-2
                                                                               Left                 Caucasian    Latino                  K-3
Ship To:                                                                       Right                Negroid      Other                   K-4
Address:


Practitioner:
Phone #:                                                                   In-Office Request Date:                                    am         pm


(Select One)
                                                                                       Please draw alignment lines on the cast
   SS       Ti              AL

TYPES OF COMPONENTS

                                          Hip Joint

                                          Thigh
                                                                                          Thigh
                                          Pylon
                                                                                                                             IT to Floor
                                          Tube Clamp

                                          Knee                                              KC


                                          Foot Plate

                                          Foot/Style/Size
                                                                                                                             KC to Floor
                                                                                           Calf
                                          Heel Height


                     TYPE OF SOCKET
     Hip   Socket   Plaster Cast Preparation
     Hip   Socket   Plaster Cast Modification                                             Ankle
     Hip   Socket   Transfer
     Hip   Socket   Check Socket
     Hip   Socket   Lamination
     Hip   Socket   Copoly
     Hip   Socket   One Shot Lamination
       (“Littig” type joint only)
     Hip Socket Setup Endo                                                 SPECIAL INSTRUCTIONS:

           FINISH HIP ENDOSKELETAL
     Hip Finish Foam Cover
     Hip Finish Lamination

                       LINERS
     Hip Liner Thermoflex
     Hip Liner Polyethylene
     Hip Liner Pelite
HD v4p1 [www]                                                                                                                              DA 03/10/2011