TF Double Wall Socket Fabrication
TF Channel/Pin
Please Select
TF Channel/Pin
Patient Name:
*
First Initial
Last Name
Encounter # / PO #:
*
Practitioner:
*
Clinic Location:
*
Please Select
Alpena (786100)
Big Rapids (781800)
Bloomington (317000)
Cadillac (786300)
Carmel (317100)
Charlotte (318500)
Charlotte (477800)
Columbus (317200)
Danville (317700)
Evansville (317300)
Fort Wayne (006100)
Gaylord (786500)
Greenwood (317400)
Holland (016800)
Indianapolis (317500)
Indianapolis (780800)
Indianapolis (785200)
Jackson (013700)
Kokomo (785700)
Lexington (317800)
Lexington (007900)
Livonia (774400)
London (317900)
Louisville I (318000)
Louisville II (318100)
Louisville III (008100)
Marquette (787400)
Monroe (318700)
Mooresville (318800)
Morehead (318200)
Mt. Sterling (318300)
Paducah (000100)
Paducah (318400)
Petoskey (787700)
Portsmouth (006500)
Prestonsburg (007901)
Richmond (475700)
Roseville (772900)
Seymour (317600)
Somerset (028100)
South Bend (765100)
Traverse City (788100)
Waterford (780000)
Other (Approval Required)
Email
*
example@example.com
Today's Date:
*
 -
Month
 -
Day
Year
Date
Due Date (3 week standard turn around):
 -
Month
 -
Day
Year
Date
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TF Channel/Pin Socket Fabrication
Patient Information
Weight:
*
Age:
*
Affected Side:
*
Left
Right
K-Level:
*
K1
K2
K3
K4
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TF Channel/Pin Socket Fabrication
Alignment
Method of Transfer:
*
Neutral (All Planes)
Transfer From Components
Transfer From Lines
I need to make changes to my alignment:
Transverse Changes
Coronal Changes
Sagittal Changes
Transverse Changes:
Please Select
Internally Rotate Knee
Externally Rotate Knee
Number of Degrees:
Coronal Changes (Angular):
Please Select
Abduct Socket
Adduct Socket
Number of Degrees:
Coronal Changes (Linear):
Please Select
Inset Knee/Foot
Outset Knee/Foot
Number of Inches:
Sagittal Changes (Angular):
Please Select
Flex Socket
Extend Socket
Number of Degrees:
Sagittal Changes (Linear):
Please Select
Anterior Shift Knee
Posterior Shift Knee
Set to TKA
Number of Inches:
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TF Channel/Pin Socket Fabrication
Modifications
I need plaster modifications:
*
Yes
No
Decrease Model:
Globally (standard)
Circumferentially
Increase Model:
Globally (standard)
Circumferentially
Amount of Change:
1 Ply
2Ply
3 Ply
5 Ply
Other
Follow instructions on diagnostic socket (for modifications only)
Areas needing plaster mods marked on diagnostic socket
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TF Channel/Pin Socket Fabrication
Suspension / Distal Attachment
Suspension/Pin:
*
Standard "Ossur Style" VLC-312 Pin w/Receiver
Other
Basic Distal Attachments:
*
4-Hole Plate (no valve)
Crows Foot (three prong)
Other
Basic 4-Hole Plate:
*
Standard 9.5mm "low-profile" (Bulldog FHLA-3)
Square Shaped 11mm (Bulldog FHLAS-11)
Heavy Duty 450lb Rated (Trulife AAASMP450)
Other
Crows Foot:
*
Low-profile 9.5mm crows foot
Deep depth 14mm crows foot (use with OB rotator or similar)
Other
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TF Channel/Pin Socket Fabrication
Inner Cup
Cup Material:
*
Rigid Carbon - Black
Flexible Resin - Black
Valve Inside Cup:
*
ST&G XP Valve
Other
Valve Location On Distal Cup:
*
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TF Channel/Pin Socket Fabrication
Inner Liners
Flexible Inner Liner:
*
Proximal Flexible - Overlap Cup
Proximal Flexible - DO NOT Overlap Cup
Flexible Type/Method:
*
Seam/Drape Formed
Bubble/Blister Formed
Seam/Drape Formed Thickness:
*
1/8"
3/16"
Bubble/Blister Formed Thickness (thickness may vary depending on limb shape/size):
*
~1/8"
~3/16"
Seam/Drape Formed Color/Material:
*
Black - Op-Tek Flex (no silicone)
White - Op-Tek Flex Comfort (with silicone)
Bubble/Blister Formed Color/Material:
*
Black - Orfitrans Excel (no silicone)
White - Orfitrans Extra Soft (with silicone)
Orfitrans Medium-Soft (stiff material, opaque white, no silicone) *BACKORDERED*
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TF Channel/Pin Socket Fabrication
Add-Ons and Trim
Amount of Inner Liner Exposed:
*
1/4"
1/2"
1"
Leave 1/4" at IT
Leave Flush at IT
Inner Liner Attachment Method:
*
Double Sided Tape
Velcro
Chicago Screw
Lamination Dots
No Attachment
Add-Ons (as marked):
RevoFit System
Window(s)
Posterior Cut-out With Dacron Strap
Felt in lamination
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TF Channel/Pin Socket Fabrication
Lamination/Finishing/Add-Ons
Finish:
*
Carbon Fiber
Skin Tone
CFAB Fabric Designs
Fabric Provided by Patient/Practitioner
Carbon Fiber:
*
Black Carbon (standard)
add Blue Pigment
add Red Pigment
add Green Pigment
Skin Tone:
*
Caucasian (#2)
Suntan (#R25)
Latino (#R45)
Light Brown (#R49)
Medium Brown (#16)
Dark Brown (#18)
PRS Pigment Swatch #___
CFAB Fabric Designs:
*
Please Select
Vintage Tie-Dye
Hologram Foil
Tropical Flowers (Discontinued)
Silver Sparkle
Pink Sparkle
Light Blue Sparkle
Colorful Feathers (Discontinued)
Polka Dots
Multi Swirls
Daisy (Discontinued)
Outer Space
American Flags
Bubbles (Discontinued)
White Lightning
Blue Lightning
Orange Flames
Blue Flames
Green Digital Camo
Grey Digital Camo
Real Woods Camo
Wood Grain
Carolina Panthers
Louisville Cardinals
Indianapolis Colts
Indiana Hoosiers
Kentucky Wildcats
Fabric Provided by Patient/Practitioner:
*
Please provide a brief description of the fabric provided with the socket and any special placement requests.
Single Color Vinyl Decal Design
Please describe or attach a single color design that is not overly intricate or detailed. Design will be placed permanently under resin.
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TF Channel/Pin Socket Fabrication
Markings on Diagnostic Socket
I have marked where the pin or attachment is to be placed:
*
Yes
I have marked the height of the distal cup:
*
Yes
I have marked the proximal AND distal termination points of the inner sealing sleeve:
*
Yes
I have marked where the proximal flexible terminates distally:
*
Yes
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TF Channel/Pin Socket Fabrication
Notes
I would like a phone call to discuss this project prior to starting fabrication
Yes
Notes:
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