Lower Extremity Prosthetic Fabrication

Transfemoral Definitive Socket Fabrication
TF
Patient Name:*

First InitialLast Name
Encounter # / PO #:*
Practitioner:*
Clinic Location:*
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Today's Date:*

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Date
Due Date:

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Date

Transfemoral Definitive Socket Fabrication

Patient Information
Weight:*
Age*
Affected Side:*

LeftRight
K-Level:*

K1K2K3K4

Transfemoral Definitive Socket Fabrication

Alignment
Method of Transfer:*

Neutral (All Planes)Transfer From ComponentsTransfer From Lines
I need to make changes to my alignment:

Transverse ChangesCoronal ChangesSagittal Changes
Transverse Changes:*
Number of Degrees:*
Coronal Changes (Angular):
Number of Degrees:
Coronal Changes (Linear):
Number of Inches:
Sagittal Changes (Angular):
Number of Degrees:
Sagittal Changes (Linear):
Number of Inches:

Transfemoral Definitive Socket Fabrication

Notes
I would like a phone call to discuss this project prior to starting fabrication

Yes
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