HFN

  • 3D TRANSTIBIAL DIAGNOSTIC SOCKET

    Intake Information

  • 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 15th. 

  • Format: (000) 000-0000.
    • Patient Information: 
    • Affected Side:*
    • Weight Unit:
    • Activity Level:
    • Design:*

    • Scanning Pathways

    • Socket IQ: 

    • Socket IQ: 

      • Scan acquired after following Socket IQ protocols.
      • Post Compression measurements required.
      • Only Color scans from Proteor Scanner accepted (OSH extension). 
    • Submission Type:*

    • Upload Scan at end.

    • Non Socket IQ: 

    • HFN 3D Printed Diagnostic: 

      • Scan acquired using any of the Hanger approved acquisition methods.
      • Measurements required. 
      • STL, AOP, FSN, and MED scans accepted. 
    • Submission Type:*
    • Scanner Type:*

    • Upload Scan at end.

    • Hanger 3D app:*
    • Combined 
    • Date*
       - -
    • Scan being submitted with order-do not delete*
      • 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:*
    • Scan Type:*

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

    • Measured Over:*
    • Tissue Type:*

  • 3D TRANSTIBIAL DIAGNOSTIC SOCKET

    Configurator
  • 0/250

  • Required Anatomical landmarks:

    • Patellar Border - Femoral Condyles - MPT - Fibular Head Border
    • Outline of Tibia Including Plateau
    • Draw Horizontal line at Mid Patella and take ML
    • PML taken at Horizontal line proximal to patella
    • Clear hash-marks min 1" in width at 1" increments for circumferences

    Optional:

    • Perimerter of Buildups/Pushes cans be drawn and filled in with diagonal lines on model
    • 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.
    • Measurements: 
    • Image field 1362
    • Non Socket IQ Measurements: 
    • Socket IQ Measurements Left: 

    • Left Circumferences:

    • Select Left Target Compression %:*

    • Left Initial Measurements:

    • Left Target {selectLeft}:

    • Left Post Compression:

    • Socket IQ Measurements Right: 

    • Right Circumferences:

    • Select Right Target Compression %:*

    • Right Initial Measurements:

    • Right Target {selectRight}:

    • Right Post Compression:

    • Design/Modifications: 
    • Image field 1693
    • Modification Type:*
    • Patella Tendon Bar:*
    • Pretibial Pushes:*

    • *Optional Additions for Modified TSB*

    • Fib Head Buildup:
    • Distal Tibia Buildup:
    • Design/Modifications: 
    • Reductions:*
    • Volume Reduction:*
    • Modification Type:*

    • Transtibial Design Types

    • Posterior Shelf:*
    • Trimlines:*
    • Revision: 

    • Global Modifications

    • Increase:
    • Decrease:
    • Percentage Increase:*
    • Ply Increase:*
    • Ply Decrease:*
    • Percentage Decrease:*
    • Socket Length:
    • Material/Suspension: 
    • Suspension:*
    • Image field 1685
    • Image field 1686

    • Componentry not provided. You will have to order the lock and have it shipped to your clinic or request in the Notes section.

    • If an attachment is required, please indicate in the Notes section.

  • 3D TRANSTIBIAL DIAGNOSTIC SOCKET

    Notes
    • 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

      

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

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  • Return Shipping Method:
  • Shipping is same as Billing Address:*
  • Requested In-Office Date:
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  • Requested In-Office Date:
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  • Daily HFN Capacity

    • Requested In-Office Date: 

    • Orders submitted after 12:00 pm will have a 3 day turnaround time due to Shipping cutoffs times. 

    • Image field 1968
    • Acknowledgements: 

    • In Clinic Reinforcement Guidelines

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