3D Printed Transfemoral Diagnostic
TF 3D
Please Select
TF 3D
Patient Name
*
First Initial
Last Name
Encounter # / PO #
*
Practitioner
*
Clinic Location
*
Please Select
Alma (786000)
Alpena (786100)
Big Rapids (781800)
Bloomington (317000)
Boston, MA (444100)
Byron Center (781900)
Cadillac (786300)
Carmel (317100)
Charlotte (318500)
Charlotte (477800)
Columbus (317200)
Danville (317700)
Evansville (317300)
Fairview Heights (780700)
Forest Park (560300)
Fort Wayne (006100)
Gaylord (786500)
Grand Rapids (772700)
Grand Rapids Mobile (790700)
Greenwood (317400)
Greenville (786900)
Holland (016800)
ICC (785000)
Indianapolis (780600)
Indianapolis (780800)
Indianapolis (785200)
Indianapolis (785500)
Jefferson (002400)
Kalamazoo (780300)
Kokomo (785700)
Lafayette (001900)
Leominster, MA (412000)
Lexington (317800)
Lexington (007900)
Livonia (774400)
London (317900)
Louisville I (318000)
Louisville II (318100)
Louisville III (008100)
Louisville IV (472000)
Marquette (787400)
Maryville (780900)
Methuen, MA (411300)
Midland (790400)
Monroe (318700)
Mooresville (318800)
Morehead (318200)
Mt. Pleasant (785800)
Mt. Sterling (318300)
Paducah (000100)
Petoskey (787700)
Plymouth, MA (443800)
Portsmouth (006500)
Prestonsburg (007901)
Richmond (475700)
Roseville (772900)
Seymour (317600)
Somerset (028100)
South Bend (765100)
South County (Tesson Ferry) (560900)
South Easton, MA (443400)
Springfield, MA (411800)
Springfield, MO (584400)
St. Peters (560800)
Support Center (318900)
Tamarac (021000)
Traverse City (788100)
Waterford (780000)
West Yarmouth, MA (443600)
Woburn, MA (444000)
Worcester, MA (411000)
Other (Approval Required)
Email
*
Please enter to receive confirmation.
Bill to PCC#:
*
Today's Date
-
Month
-
Day
Year
Date
Due Date
-
Month
-
Day
Year
Date
REVISION TO EXISTING DIAGNOSTIC
Yes
Affected Side
Back
Next
3D Printed Transfemoral Diagnostic
Patient Information
Weight
*
Age
*
Affected Side
*
Left
Right
Affected Side Container
Scan Upload
Browse Files
Drag and drop files here
Choose a file
Mark anterior if sending distal end scan.
Cancel
of
Already Modified by Clinician?
Yes
Back
Next
3D Printed Transfemoral Diagnostic
Measurements *REQUIRED*
Greater Trochanter
*
Length
Ischial Tuberosity
*
Length
Perineum
*
Length
Circumferences
Back
Next
3D Printed Transfemoral Diagnostic
Brim Style
Back
Next
3D Printed Transfemoral Diagnostic
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
Back
Next
3D Printed Transfemoral Diagnostic
Socket Length
Increase by
Decrease by
Increase Amount (Inches)
*
Decrease Amount (Inches)
*
Material
PETG
CPX
CPX Color
*
White
Black
Suspension
*
Lanyard
IN/APC/Bulldog Shuttle lock (65 mm)
Suction/Vac
Other
Flex Socket 5° and outset base 1/4"
Suspension Container
Corrugation
Extra Charge
Added to the Ischial Seat
Notes
Back
Next
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
Should be Empty: