TRANSFEMORAL/KNEE DISARTIC 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. 

  • TRANSFEMORAL/KNEE DISARTIC 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.
    • 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:*
    • Deprecated - Scan being submitted with order - Do not delete:*
    • Submission Type:*
    • Scanner Type:*

    • Upload Scan at the 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:*
    • By Measurement:*

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

    • Device Type:
    • Raven Base Code:

  • TRANSFEMORAL/KNEE DISARTIC DIAGNOSTIC SOCKET

    Configurator
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    • Measurements: 
      • Always scan/cast & measure over the liner you are fitting with.
      • Length measurements must be taken from the Perineum. 
    • Please indicate measurement unit:*
    • Image field 1362
    • Design: 
    • Reductions:*
    • Volume Reduction:*

    • Brim Style Descriptions

    • Brim Style:*
    • Image field 1649
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    • Alignment (Optional): 

    • Coronal:
    • Fabrication: 
    • Device Type:*
    • Material Type:*
    • Shape Distal end to Accept:*
    • Vacuum Forming Method:*
    • Suspension Options:*
    • Lock:*
    • Image field 1620
    • Image field 1621
    • Image field 1623

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

    • Valve:*
    • Image field 1674
    • Image field 1703
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    • Components:*
    • Image field 1628
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  • TRANSFEMORAL/KNEE DISARTIC DIAGNOSTIC SOCKET

    Notes

  • 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

      

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  • 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

  • {requestedInoffice1514}{requestedInoffice1731}{requestedInoffice1732}{requestedInoffice1733}{requestedInoffice1734}{requestedInoffice1735}{requestedInoffice1736}

    • Requested In-Office Date: 
    • Image field 1729

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

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