TRANSFEMORAL/KNEE DISARTIC DEFINITIVE SOCKET

TRANSFEMORAL/KNEE DISARTIC DEFINITIVE SOCKET

Please do not print the Review page.

Scroll to the bottom, hit Complete and then download the work order.
Legacy form will no longer be accepted.
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.
NextGen Encounter ID:
TRANSFEMORAL/KNEE DISARTIC DEFINITIVE SOCKET

Intake Information
Patient ID:
PO or Encounter #:
Clinician Name - Deprecated:
Clinician Name:

First NameLast Name
Fabrication Location:
HFN Cromwell has relocated! Our new address is:
31 Inwood Rd, Rocky Hill, CT 06067
Other Fab Location:
Clinician Email:
Please enter to receive confirmation.
Clinician Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
External
Options:
Select when only a Foam Cover is needed.
- Affected Side:
- Age:
- Affected Side-Container
- Weight Unit:
- Activity Level:
- Weight:
- Weight:
- Diagnosis:
- Deprecated - Scan being submitted with order:
- 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
  
  MonthDayYear
  Previous Model Order Date
- Provide CDC #:
- 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.
- Model Information (Optional):
- Already Modified by Clinician:
- Measured Over:
- Liner Type:
- Tissue Type:
- The Shipping section is now at the end of the form.
- Raven Base Code:
- Device Type:
- Raven Procedure Code:
- - F9015
- - F5658
- - F9024
- - F9025
- - F9036
- - F5668
- - F9006
- - F5652
- - F5671
- Raven Component Code:
- Lock:
- Valve:
- Component:

TRANSFEMORAL/KNEE DISARTIC DEFINITIVE SOCKET

Configurator
Notes:

0/250
Please indicate measurement unit:
- Go by:
- Left Selection:
- Right Selection:
- Waist:
  Length
- L - IT to Floor:
  Length
- R - IT to Floor:
  Length
- IT to Floor Container:
- L - IT to Distal End:
  Length
- R - IT to Distal End:
  Length
- IT to Distal End Container:
- L - IT to Femur Distal End:
  Circumference
- R - IT to Femur Distal End:
  Circumference
- IT to Femur Distal End Container:
- L - IT to Floor:
  Length
- R - IT to Floor:
  Length
- L - IT to Distal End:
  Length
- R - IT to Distal End:
  Length
- L - IT to Femur Distal End:
  Circumference
- R - IT to Femur Distal End:
  Circumference
- Method of Transfer:
- Best Practice (Please Acknowledge):
- i
  
  Making changes prior to definitive fabrication is not recommended.
- I need to make changes to my alignment:
- Transverse Changes:
- Amount:
- Transverse Changes:
- Internally Rotate Knee Externally Rotate Knee* * degrees from current position.
- Coronal Changes (Angular):
- Amount:
- Coronal Changes (Linear):
- Distance:
  Decimal Value Optional
- Distance:
  Decimal Value Optional
- Coronal Changes
- Coronal Changes (Angular):
- Abduct Socket Adduct Socket* * degrees from current alignment.
- Coronal Changes (Linear):
- Inset Knee/Foot Outset Knee/Foot* *in from current position.
- Inset Knee/Foot Outset Knee/Foot* *cm from current position.
- Sagittal Changes (Angular):
- Amount:
- Sagittal Changes (Linear):
- Distance:
  Decimal Value Optional
- Distance:
  Decimal Value Optional
- Sagittal Changes
- Sagittal Changes (Angular):
- Flex Socket Extend Socket* * degrees from current alignment.
- Sagittal Changes (Linear):
- TKA Container
- Anterior Shift Knee Posterior Shift Knee* *in from current position.
- Anterior Shift Knee Posterior Shift Knee* *cm from current position.
- Modifications Required:
- Modification Type:
- i
  
  Global modifications will affect the distal end of the model.
- Decrease Model:
- Increase Model:
- Amount:
  
  Other
- Follow instructions on diagnostic socket (for modifications only):
- Diagnostic Socket marked:
- Suspension Options:
- Lock:
  
  Other
- Lock not provided. If needed, Please write in the Lock request in the Notes need.
- Pin not provided.
- Coyote Lock Depth:
- Lanyard:
  
  Other
- Best Practice (Please Acknowledge):
- Suction/Vacuum:
- Valves (integrated/mounted onto socket):
  
  Other
- Valve Install Location:
  
  Other
- Suction/Vacuum Integrated Plates:
  
  Other
- Distal Attachments:
- 4-Hole Plate (No Valve):
  
  Other
- 3 Prong/4 Prong Adapter:
  
  Other
- Inner Liner Type:
- Soft/Foam Inner Liners:
  
  Other
- Flexible Type/Method:
- Seam/Drape Formed Color/Material:
  
  Other
- Bubble/Blister Formed Color/Material:
  
  Other
- i
  
  Finished Plastic Thickness will be within 10% of the requested thickness.
- Seam/Drape Formed Finished Thickness:
- Bubble/Blister Formed Thickness:
- Socket Add Ons:
- Socket Add Ons:
- Distal End Pad Material:
  
  Other
- Distal End Pad Thickness:
  
  Other
- Distal End Pad Thickness:
  Decimal Value Optional
- Distal End Pad Thickness:
- Add Ons (Window/Cutout/RevoFit):
- Add Ons:
- Add Ons:
- Best Practice (Please Acknowledge):
- Best Practice (Please Acknowledge):
- Window Location:
- RevoFit Design:
- Panel:
- Gap:
- RevoFit Reel Location:
- Frame Mounted (Height):
- Frame Mounted (Side):
- Pad Thickness:
- Amount of Inner Liner Exposed:
  
  Other
- Inner Liner Attachment Method:
- Inner Liner Attachment Method - Velcro
- Finish:
- Carbon Fiber:
- Skin Tone:
  
  PRS Pigment Swatch #___
- Skin Tone:
- Color/Swatch #:
- Fabric Provided by Patient/Practitioner:
  Please provide a brief description of the fabric provided with the socket and any special placement requests.
- Options:
- Foam Cover:
- Sound Side Measurements:
- Foot Size:
- Calf Circumference:
- Proximal Ankle Circumference:
- MPT to Floor:
- - 2":
- - 4":
- - 6":
- - 8":
- Calf Circumference:
- Proximal Ankle Circumference:
- MPT to Floor:
- - 5 cm:
- - 10 cm:
- - 15 cm:
- - 20 cm:
- Cover Process:
  
  Other

TRANSFEMORAL/KNEE DISARTIC DEFINITIVE 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
Scan Upload:

Accepted File types: med, fsn,aop, op3, stl, sm1 - 250 MB File Size Limit
Cancelof
Average Cast Thickness - Left (mm):
Decimal Value Optional
Average Cast Thickness - Right (mm):
Decimal Value Optional
Technical Consult: I would like a call to discuss prior to starting fabrication.
Who would you like a call from?
Technical Consult Team:
Notes:

0/250
Upload Supporting Images (Optional):

Allowed Image types: jpg, jpeg, png, gif
Cancelof
Return Shipping Method:
Return Shipping Method:
Shipping is same as Billing Address:
Bill to PCC#:
Ship to PCC#:
Ship to Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Bill to Address:

Street Address

Street Address Line 2

CityState

Zip Code
Bill to Address:
Hospital Call/Fast Track:
Hospital Call/Fast Track
Requested In-Office Date:

MonthDayYear
Order ship date may be impacted by incomplete order, component availability and upon cast receipt (for physical orders).
Requested In-Office Date:

MonthDayYear
Order ship date may be impacted by incomplete order, component availability and upon cast receipt (for physical orders).
Requested In-Office Date:

MonthDayYear
Order ship date may be impacted by incomplete order, component availability and upon cast receipt (for physical orders).
Requested In-Office Date:

MonthDayYear
Order ship date may be impacted by incomplete order, component availability and upon cast receipt (for physical orders).
Requested In-Office Date:

MonthDayYear
Order ship date may be impacted by incomplete order, component availability and upon cast receipt (for physical orders).
Requested In-Office Date:

MonthDayYear
Order ship date may be impacted by incomplete order, component availability and upon cast receipt (for physical orders).
Requested In-Office Date:

MonthDayYear
Order ship date may be impacted by incomplete order, component availability and upon cast receipt (for physical orders).
Daily HFN Capacity
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- Clinicians can still coordinate special in-office requests by emailing:
  HFN_Support@hanger.com
- Bilateral
- Today's Date:
  
  MonthDayYear
  Date
  Hour MinutesAM/PM Option
Should be Empty: