UCB, SMO

You can still access the legacy PDF work order.
UCB, SMO

Intake Information
Patient ID:*

First InitialLast Name
PO or Encounter #:*
Clinician Name:*
Fabrication Location:*
Other Fab Location:*
Fab PCC#:*
Fab Location:
Please enter a correct Fab PCC#
Clinician Email:*
Please enter to receive confirmation.
Clinician Phone Number:*
Please enter a valid phone number.
Hospital Call/Fast Track

Yes
Requested In-Office Date:

MonthDayYear
Date
Daily HFN Capacity
Hospital Call/Fast Track
Return Shipping Method:

GroundStandard 2 DayOvernight: PriorityOvernight: 1stLocal/Pickup
Return Shipping Method:*
Return Shipping Method:*
Shipping is same as Billing Address:*

YesNo
Bill to PCC#:*
Ship to PCC#:*
Bill to Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Ship to Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Today's Date:*

MonthDayYear
Date

UCB, SMO

Device Type
Device Type*
Raven Base Code:

F1960 - AFO, THERMOPLASTIC SOLID ANKLE OR FLOOR REACTIONF3000 - UCB INSERT/FLEXIBLE INNER BOOT, EACH
Device Type

UCBSMO

UCB, SMO

Notes
Technical Consult: I would like a call to discuss prior to starting fabrication.

Yes
Who would you like a call from?*

Modifications (Modifier)Design options on device (Fab Supervisor)Shipping/Billing (Customer Support)
Technical Consult Team:
Notes:

0/250
Image upload (Optional)

Allowed Image types: jpg, jpeg, png, gif
Cancelof
Bilateral
-F0053
-F1101
-F0040
-F0040
-F2840
-F2820
-F2820
-F2820
-F1915
-F9036
-F0046
Should be Empty:

Intrinsic Heel Skive requires external posting.