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.

  • - Please create a new account to use the Save Draft feature - 

  • TRANSTIBIAL/SYMES DEFINITIVE SOCKET

    Intake Information

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

  • Select when only a Foam Cover is needed. 

    • Patient Information: 

    • 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. 

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      • 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. 

        

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

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    • Daily HFN Capacity

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

    • Requested In-Office Date: 
    • Image-1859

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

  • TRANSTIBIAL/SYMES DEFINITIVE SOCKET

    Intake Information
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    • Measurements: 
    • Image-1362
    • Alignment: 

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      Making changes prior to definitive fabrication is not recommended.

    • Transverse Changes:

    • * * degrees from current position.

    • Coronal Changes (Angular):

    • * * degrees from current alignment.

    • Coronal Changes (Linear):

    •  * *in from current position.

    • * *cm from current position.

    • Sagittal Changes (Angular):

    •  * * degrees from current alignment.

    • Sagittal Changes (Linear):

    •  * *in from current position.

    •  * *cm from current position.

    • Modifications: 

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      Global modifications will affect the distal end of the model. 

    • Fabrication: 
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    • Lock not provided. 

    • Pin not provided. 

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

    • Finishing: 
    • Image-1728
    • Image-1729

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

    • Image-1730
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    • Supracondylar will be Frame Mounted at the Midshaft on the {hingeLocation} side.

    • Foam Cover 

    • Foam Cover:

    • Image-1842

    • Sound Side Measurements:

  • TRANSTIBIAL/SYMES DEFINITIVE 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 and submit the form and print out the Work Order PDF. In the Hanger 3D app, go to Order Forms > Take a Picture and upload the printed PDF along with your scan.

      

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