TRANSTIBIAL/SYMES DIAGNOSTIC SOCKET

  • 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 Nov 1st. 

  • TRANSTIBIAL/SYMES DIAGNOSTIC SOCKET

    Intake Information

  • HFN Rocky Hill (Cromwell) has relocated! Our new address is:
    31 Inwood Rd, Rocky Hill, CT 06067

  • Format: (000) 000-0000.
  • 0/250
    • Patient Information: 
    • Affected Side:*

    • Bilateral Symmetrical: 

      • Left and Right sides can have different Measurements
      • Same Alignment, Design and Finishing options
    • Bilateral:*
    • Bilateral Type:*
    • Weight Unit:
    • Activity Level:
    • Amputation Level:*
    • Deprecated - Scan being submitted with order - Do Not Delete:*
    • Submission Type:*
    • Scanner Type:*

    • Upload Scan at end.

    • Hanger 3D app:*

    • Submission Type:

      • Diagnostic Socket
      • Plaster Cast: Negative or Positive

        Please include a printed Work Order with the cast when shipping.

    • Your order will be sent to CDC after submission. 

    • Date:*
       - -
    • Is this a Hanger3D app scan?*
      • Please complete this form. Next, after acquiring the scan via the Hanger3D app, go to Order Forms > Jotform Order and fill out the required information and submit the scan. NO OTHER ACTION IS NEEDED

        

    • Scan Type:*

    • The Cast Measurement fields are available at the end of the Form. 

    • Already Modified by Clinician:*
    • Measured Over:*
    • Tissue Type:*

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

    • Raven Base Code:
    • Device Type:

  • TRANSTIBIAL/SYMES DIAGNOSTIC SOCKET

    Configurator
  • Please indicate measurement unit:*
    • Measurements: 
      • Always scan/cast & measure over the liner you are fitting with.
      • Measurements required at 1" (2.5 cm) intervals.
      • Anatomical landmarks of MPT, Fibular Head, & Distal Tibia must be located on the scan/cast.
    • Image field 1362
    • Design: 
    • Reductions:*
    • Volume Reduction:*
    • Modification Type:*

    • Transtibial Design Types

    • Posterior Shelf:*
    • Modifications: 
    • Modifications Required:*
    • Modifications Type:*

    • i

      Global modifications will affect the distal end of the model. 

    • Decrease Model:*
    • Increase Model:*
    • Amount:*
    • Fabrication: 
    • Device Type:*
    • Device Type:*
    • Shape Distal end to Accept:*
    • Material Type:*
    • Vacuum Forming Method:*
    • Suspension Options:*
    • Lock:*
    • Image field 1620
    • Image field 1731
    • Image field 1622
    • Image field 1794
    • Image field 1623
    • Image field 1624

    • Lock not provided. If needed, Please write in the Lock request in the Notes field.

    • Pin not provided. 

    • Coyote Lock Depth:*
    • Suction/Vacuum:*
    • Valves (integrated/mounted onto socket):*
    • Image field 1625
    • Image field 1797
    • Image field 1798
    • Image field 1626
    • Image field 1627
    • Image field 1642
    • Valve Install Location:*
    • Suction/Vacuum Integrated Plates:*
    • Image field 1800
    • Image field 1801
    • Image field 1802
    • Image field 1803
    • Components:*
    • Distal Attachments:*
    • 4-Hole Plate (No Valve):*
    • Image field 1628
    • Image field 1807
    • Image field 1808
    • Image field 1629
    • Image field 1809
    • 3 Prong/4 Prong Adapter:*
    • Image field 1630
    • Image field 1631
    • Image field 1632
    • Inner Liner Type:
    • Soft/Foam Inner Liners:*
    • Flexible Type/Method:*
    • Seam/Drape Formed Color/Material:*
    • Bubble/Blister Formed Color/Material:*

    • i

      Finished Plastic Thickness will be within 10% of the requested thickness.

    • Seam/Drape Formed Finished Thickness:*
    • Bubble/Blister Formed Finished Thickness:*
    • Add Ons:
    • Add Ons:
    • Distal End Pad Material:*
    • Distal End Pad Thickness:*
    • Trimlines:*
    • Amount of Inner Liner Exposed:*
    • Inner Liner Attachment Method:*

  • TRANSTIBIAL/SYMES DIAGNOSTIC SOCKET

    Notes

  • Your order will be sent to CDC after submission along with the Scan. No futher action is needed.

    (No Entry required at the Sharepoint portal)

  • Your order will be sent to CDC after submission. No futher action is needed.

    (No Entry required at the Sharepoint portal)

    • Please complete this form. Next, after acquiring the scan via the Hanger3D app, go to Order Forms > Jotform Order and fill out the required information and submit the scan. NO OTHER ACTION IS NEEDED

      

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Who would you like a call from?*
  • 0/250
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Return Shipping Method:
  • Shipping is same as Billing Address:*
  • Requested In-Office Date:
     - -
  • Requested In-Office Date:
     - -
  • Requested In-Office Date:
     - -
  • Requested In-Office Date:
     - -
  • Requested In-Office Date:
     - -
  • Requested In-Office Date:
     - -
  • Requested In-Office Date:
     - -

  • Daily HFN Capacity

  • {requestedInoffice}{requestedInoffice1776}{requestedInoffice1777}{requestedInoffice1778}{requestedInoffice1779}{requestedInoffice1780}{requestedInoffice1781}

    • Requested In-Office Date: 
    • Image field 1774

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

    • Today's Date:*
       - -
  • Should be Empty: