Finish Lab Form

Finish Lab Form

Finish Lab Form

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Date
MM slash DD slash YYYY
Share Drive Video/Photo Share Link
ID# (if known)
Patient Name*
First Last
Office*
Practitioner*
Patient Info
Height (Inches)*
Weight (lbs)*
Side*
Location of the Amputation*
Type*
Skin Tone*
Replacement
Adapters*
AK Opening
BK Openings - Reliefs
Mid-Calf Circ
Above Ankle Circ
MPT - Floor Height
Height of Cover
Knee Center to Floor Height
Materials & Components
Flexible Inner Liners*
Suspension*
Cover*
Flexion Plate*
Offset*
Additional Information
Include any additional necessary information, such as it being part of a BiLateral, specific adjustments, etc.
Upload Video
Accepted file types: mov, mp4, avi, wmv, 3gp, 3g2, m4v, mkv, ogv, webm, zip, Max. file size: 250 MB.
Max File Size: 250MB
Upload Images
Drop files here or

Accepted file types: jpg, jpeg, gif, png, pdf, zip, Max. file size: 250 MB, Max. files: 6.
Upto 6 Images. Max File Size: 250MB
Ordering
Foot Size/Model
Knee Type/Model

(OFM2, Total Knee 2000, Other)
Delivery Specifications
Attachments of Photos or Molds*
Do you want to send the Lab a photo or the mold?
- Yes
- No
When does the prosthesis need to be there?*
Date needed by*
MM slash DD slash YYYY

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