REPAIR ORDER FORM

Please do not print the Review page.

Scroll to the bottom, hit Complete and then download the work order.
NextGen Encounter ID:
THIS FORM IS FOR EXISTING DEVICE REPAIRS ONLY. PLEASE FILL OUT A DEVICE FORM FOR REDO/REWORK.
REPAIR ORDER FORM

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

First NameLast Name
Fabrication Location:
Other Fab Location:
Clinician Email:
Please enter to receive confirmation.
Clinician Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Hospital Call/Fast Track:
Hospital Call/Fast Track
External
- Affected Side:
- Bilateral:
- Age:
- Bilateral Type:
- Affected Side-Bilat Sym
- Affected Side-Bilat Asymmetrical
- Weight Unit:
- Diagnosis:
- Weight:
- Weight:
- Submission Type:
- Submission Type:
  - Physical Device
    
    Please include a printed Work Order with the device when shipping.
- The Shipping section is now at the end of the form.
- Raven Base Code:
- Raven Component Code:
- Raven Procedure Code:
- Bilateral
- Device Type:
- Other Device Type:
- Device Type:
- Raven Base Code:
- Device Type
- Technical Consult: I would like a call to discuss prior to starting fabrication.
- Who would you like a call from?
- Technical Consult Team:
- Notes:
  
  0/1000
- 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:
- 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
- Today's Date:
  
  MonthDayYear
  Date
  Hour MinutesAM/PM Option
- Should be Empty: