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.

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

Please enter to receive confirmation.

Please enter a valid phone number.Format: (000) 000-0000.

LeftRightBilateral Symmetrical

Bilateral Symmetrical:

Left and Right sides can have different Measurements
Same Alignment, Design and Finishing options

SymmetricalAsymmetrical

Physical CastScanHanger3DUse Previous Digital Model

TechmedInsigniaComb app

Upload Scan at end.

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.

Previous Model Order Date

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

Direct PatientPositive ModelOutside Cast ScanClinician Premodified (Digitally)

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

Already Modified by Clinician

Need more AdjustmentsNo Further changes needed

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

F5620 - BK TEST SOCKETF5530 - BK POLYPRO SOCKETF6020 - V-PIN BK SOCKET COMPLETEF8101 - BELOW-KNEE / TRANSTIBIAL

TT DIAGNOSTIC SOCKETTT POLYPRO SOCKETV-PIN SOCKETTT CARVING

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.

CDC Standard Reduction (based on Liner/Tissue Type)Volume Reduction

None (Already modified)W BackStraightDiagonal

V-Pin Socket OnlyV-Pin Socket & Carving

Carving OnlyDiagnostic Socket OnlyDiagnostic Socket & Carving

NoneAdult Shuttle LockPediatric Shuttle Lock

Vivak (PETG)Orfitrans StiffCopolyPolypro

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

Pin not provided.

PosteriorMedialLateralOther

Neutral Zero - All PlanesOther

No Inner LinerFlexible PlasticSoft/Foam Inner Liners

Keasy ConeBocklite (Tan) 5 mmPelite (White) 8 mmOther

Seam/Drape FormedBubble/Blister Formed

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

1/8" (3 mm)3/16" (5 mm)

Stove PipePull StrapsSupracondylar WedgeDistal End Pad

Pull StrapsSupracondylar WedgeDistal End Pad

PlastazoteAliplastOther

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

Decimal Value Optional

Modifications (Modifier)Design options on device (Fab Supervisor)Shipping/Billing (Customer Support)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Street Address

Street Address Line 2

CityState

Zip Code

Order ship date may be impacted by incomplete order, component availability and upon cast receipt (for physical orders).

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

Date

Hour MinutesAM/PM Option