TRANSTIBIAL/SYMES DEFINITIVE 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.

Access Legacy PDF work order. Legacy form will be accepted until Mar 4th.

Legacy form will no longer be accepted.

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.

Select when only a Foam Cover is needed.

LeftRightBilateral (Symmetrical)

Physical CastScanHanger3DUse Previous Digital Model

TechmedInsigniaComb app

Upload Scan at the 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.

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

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.

F5701 - TT SINGLE LAMINATIONF5700 - TT LAMINATED SOCKET

TT SINGLE LAMINATIONTT DOUBLE LAMINATION

ImpressionMeasurements

Neutral (All Planes)Transfer From ComponentsTransfer From Lines

Coronal and Sagittal alignment lines have been marked on the cast/diagnostic socket.

Making changes prior to definitive fabrication is not recommended.

Transverse ChangesCoronal ChangesSagittal Changes

Transverse Changes:

Internally Rotate Foot Externally Rotate Foot* * degrees from current position.

Decimal Value Optional

Coronal Changes (Angular):

Abduct Socket Adduct Socket* * degrees from current alignment.

Coronal Changes (Linear):

Inset Foot Outset Foot* *in from current position.

Inset Foot Outset Foot* *cm from current position.

Decimal Value Optional

Sagittal Changes (Angular):

Flex Socket Extend Socket* * degrees from current alignment.

Sagittal Changes (Linear):

Shift Foot Anterior Shift Foot Posterior* *in from current position.

Shift Foot Anterior Shift Foot Posterior* *cm from current position.

Decrease ModelIncrease Model

Global modifications will affect the distal end of the model.

Globally (Standard)Circumferentially

Areas needing modifications marked on diagnostic socket.

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

Pin not provided.

Regular for 8-click pinDeeper for 11-click pin

Plate with distal valve includedValve mounted on/integrated into socket

CA200-AVPIcelock 551Unity ValveOther

4-Hole Plate (No Valve)3 Prong/4 Prong Adapter

3-Prong Rotatable Pyramid4-Prong Male3-Prong Rotatable ReceiverOther

No Inner LinerFlexible Plastic -FullFlexible Plastic - Proximal OnlySoft/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

Decimal Value Optional

Double Sided TapeVelcroChicago ScrewNo Attachment

Window(s)Door (overlapping)Felt in laminationRevoFit System

Window(s)RevoFit System

Location/size/shape of Add Ons have been marked on the Diagnostic socket.

Panel Shapes/Dial Location/Lace Routing has been marked on the Diagnostic socket.

Window (no panel or straps)Overlap Window (straps included)

Posterior (1)Anterior (2)

Gap Design (2 Posterior Gaps) will be Frame Mounted at the Posterior Proximal aspect of the socket.

Hinged Open PosteriorSupracondylar

Supracondylar will be Frame Mounted at the Midshaft on the {hingeLocation} side.

Frame MountedPanel Mounted

ProximalMidshaftDistal

1/8" (3 mm)1/4" (6 mm)3/8" (9 mm)

Carbon FiberSkin ToneFabric Provided by Patient/Practitioner

Black (standard)add Blue Pigmentadd Red Pigmentadd Green Pigment

PRS 1-18KinglseyOttobock 1-18

Please provide a brief description of the fabric provided with the socket and any special placement requests.

Sound Side Measurements:

Decimal value optional

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).

{requestedInoffice1514}{requestedInoffice1861}{requestedInoffice1862}{requestedInoffice1863}{requestedInoffice1864}{requestedInoffice1865}{requestedInoffice1866}

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

Date

Hour MinutesAM/PM Option