CUSTOM TRANSTIBIAL AMPUSHIELD

  • Please do not print the Review page.

    Scroll to the bottom, hit Complete and then download the work order.

  • Access Legacy PDF work order. Legacy form will be accepted until Sep 1st. 

  • CUSTOM TRANSTIBIAL AMPUSHIELD

    Intake Information
  • Format: (000) 000-0000.
    • Patient Information: 
    • Bilateral:*
    • Bilateral Type:*
    • Affected Side:*

    • Bilateral Symmetrical: 

      • Left and Right sides can have different Measurements
      • Same Alignment, Design and Finishing options
    • Weight Unit:

    • The Shipping section is now at the end of the form.

    • Raven Base Code:
    • Raven Procedure Code:
    • Left Raven Base Code:
    • Left Raven Procedure Code:
    • Right Raven Procedure Code:
    • Right Raven Base Code:
    • Device Type-Global:
    • Left Device Type-Global:
    • Right Device Type-Global:

  • CUSTOM TRANSTIBIAL AMPUSHIELD

    Configurator
  • 0/250
    • Measurements: 
    • Please indicate measurement unit:*
    • Image field 1362
    • Image field 1363
      • Flexion angles greater than 20 degrees require a Rigid PE Protector with step locks. Device will be designed neutral and can be adjusted at fitting.
    • Design: 
    • Image field 1519
    • Image field 1520
    • Image field 1521
    • Image field 1529

    • IMPORTANT: Proximal Trim length from MPT must be a minimum of 8" (20 cm) for
      Semi-Rigid frame. 

    • Device Type:*
    • Device Type:*
    • Left Device Type:*
    • Left Device Type:*
    • Right Device Type:*
    • Right Device Type:*
    • Rigid PE Protector Type:*
    • Left Rigid PE Protector Type:*
    • Right Rigid PE Protector Type:*

    • i

      Ventilation is an option for an Unlined Rigid Protector. 

    • Variation:
    • Left Variation:
    • Right Variation:

    • i

      Fabrication will adjust distal length to accommodate for end pad. 

    • Distal End Pad:

    • Ships with additional 1" adjustment pad. 

  • CUSTOM TRANSTIBIAL AMPUSHIELD

    Notes
  • Who would you like a call from?*
  • 0/250
  • Weekend Delivery?*
  • Return Shipping Method:
  • Shipping is same as Billing Address:*
  • Today's Date:*
     - -
  • Is the Shipping address a Residential address?*
  • Requested In-Office Date:
     - -
  • Requested In-Office Date:
     - -
  • Requested In-Office Date:
     - -
  • Requested In-Office Date:
     - -
  • Requested In-Office Date:*
     - -

  • Daily HFN Capacity

  • {requestedInoffice}{requestedInoffice1570}{requestedInoffice1571}{requestedInoffice1572}

    • Requested In-Office Date: 
    • Image field 1577

    • Clinicians can still coordinate special in-office requests by emailing:
      HFN_Support@hanger.com

  • Should be Empty: