3D TRANSTIBIAL 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 15th.

First InitialLast Name

Please enter to receive confirmation.

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

Socket IQ:

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

Upload Scan at end.

HFN 3D Printed Diagnostic:

Scan acquired using any of the Hanger approved acquisition methods.
Measurements required.
STL, AOP, FSN, and MED scans accepted.

Upload Scan at end.

Previous Model Order Date

Previous Model PO/Encounter #

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.

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

Length - Multiply inch value by 25.4

Left Circumferences:

Left Initial Measurements:

Left Target {selectLeft}:

Left Post Compression:

Right Circumferences:

Right Initial Measurements:

Right Target {selectRight}:

Right Post Compression:

Multiply inch value by 25.4

Componentry not provided. You will have to order the lock and have it shipped to your clinic.

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.

Decimal Value Optional

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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Daily HFN Capacity

Date

Hour MinutesAM/PM Option

3D TRANSTIBIAL DIAGNOSTIC SOCKET