3D Printed Transtibial Diagnostic
TT 3D
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TT 3D
Patient Name
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First Initial
Last Name
Encounter # / PO #
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Practitioner
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Clinic Location
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Please Select
Alma (786000)
Big Rapids (781800)
Bloomington (317000)
Byron Center (781900)
Carmel (317100)
Charlotte (318500)
Charlotte (477800)
Columbus (317200)
Danville (317700)
Evansville (317300)
Fort Wayne (006100)
Grand Rapids (772700)
Greenwood (317400)
Greenville (786900)
Holland (016800)
ICC (785000)
Indianapolis (317500)
Indianapolis (780600)
Indianapolis (780800)
Kalamazoo (780300)
Kokomo (785700)
Lexington (317800)
Lexington (007900)
London (317900)
Louisville I (318000)
Louisville II (318100)
Louisville III (008100)
Louisville IV (472000)
Marquette (787400)
Midland (790400)
Monroe (318700)
Mooresville (318800)
Morehead (318200)
Mt. Pleasant (785800)
Mt. Sterling (318300)
Paducah (000100)
Paducah (318400)
Petoskey (787700)
Seymour (317600)
Somerset (028100)
South Bend (765100)
Support Center (318900)
Tamarac (021000)
Other (Approval Required)
Email
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Bill to PCC#
*
Today's Date
-
Month
-
Day
Year
Date
Due Date
-
Month
-
Day
Year
Date
REVISION TO EXISTING DIAGNOSTIC
Yes
Affected Side
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3D Printed Transtibial Diagnostic
Patient Information
Weight
*
Age
*
Affected Side
*
Left
Right
Affected Side Container
Scan Upload
Browse Files
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Choose a file
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Already Modified by Clincian?
Yes
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3D Printed Transtibial Diagnostic
Measurements *REQUIRED*
AP
*
ML
*
PML
*
Length
*
MPT to Distal
Circumferences
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3D Printed Transtibial Diagnostic
Modifications to Scan
PTB
Shape:
Straight
Arc
Depth
*
1/8"
3/16"
1/4"
Other
Pre-Tib Mods
Depth:
Standard
Custom
Custom Values
Anterior Distal Tibia
Build up:
1/8"
3/16"
1/4"
Other
Fibular Head
Build up:
1/8"
3/16"
1/4"
Other
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3D Printed Transtibial Diagnostic
PML Width
Reduce Medial:
1/8"
3/16"
1/4"
Other
Reduce Lateral:
1/8"
3/16"
1/4"
Other
Global Modifications
Increase
Percentage
Ply
Decrease
Percentage
Ply
Percentage Increase
*
2%
3%
4%
Other
Ply Increase
*
1
3
5
Other
Ply Decrease
*
1
3
5
Other
Percentage Decrease
*
2%
3%
4%
Other
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3D Printed Transtibial Diagnostic
Socket Length
Increase by
Decrease by
Increase Amount (Inches)
*
Decrease Amount (Inches)
*
Shelf
Style
*
Straight
Slant
W
Already modified
Placement
*
At PTB
Above PTB
Below PTB
Already modified
Below PTB
*
1/4"
1/2"
3/4"
Above PTB
*
1/4"
1/2"
3/4"
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3D Printed Transtibial Diagnostic
Trimlines
*
Standard (65 mm)
Extended (75 mm)
Supracondylar (90 mm)
Already modified
Suprapatellar
Material
PETG
CPX
CPX Color
*
White
Black
Suspension
*
Pinlock (65 mm)
Suction/Vac
Other
Coyote Airlock Drop in (C10A)
Coyote Suction Drop in (CD120SP)
Ossur Icelock 562 Hybrid
Other
Componentry not provided. You will have to order the lock and have it shipped to your clinic.
Corrugation
Extra Charge
Added to the Proximal "Wings"
Notes
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All Diagnostic sockets must be reinforced with casting tape before walking patients.
*
I agree
PETG Diagnostic sockets are for in office use only.
*
I agree
Submit
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