REPAIR ORDER FORM

Please do not print the Review page.

Scroll to the bottom, hit Complete and then download the work order.
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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.
Yes
Hospital Call/Fast Track
External
- LeftRightBilateral
- YesNo
- Age:
- Symmetrical (Single Work order)Asymmetrical (Separate Work orders for each side)
- Affected Side-Bilat Sym
- Affected Side-Bilat Asymmetrical
- lbskg
- Diagnosis:
- Weight:
- Weight:
- Physical Cast
- Submission Type:
  - Physical Device
    
    Please include a printed Work Order with the device when shipping.
- Ground2-dayPriority OvernightFirst OvernightLocal CourierPick up
- Return Shipping Method:*
- YesNo
- 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
- F5624 - AK TEST SOCKETF5580 - AK POLYPRO SOCKETF8102 -ABOVE-KNEE / TRANSFEMORAL
- TF DIAGNOSTIC SOCKETTF POLYPRO SOCKETTF CARVING
- Raven Component Code:
- Raven Procedure Code:
- Bilateral
- Device Type:*
- Other Device Type:*
- Device Type:*
- F1960 - AFO, THERMOPLASTIC SOLID ANKLE OR FLOOR REACTIONF1970 - ARTICULATED PLASTIC AFO
- SOLIDSEMI-SOLIDPOSTERIOR LEAF SPRINGARTICULATED W/STOPARTICULATED (FREE MOTION)ARTICULATED (POSTERIOR ENTRY)
- Yes
- Modifications (Modifier)Design options on device (Fab Supervisor)Shipping/Billing (Customer Support)
- Technical Consult Team:
- Notes:
  
  0/1000
- Image Upload (Optional):
  
  Allowed Image types: jpg, jpeg, png, gif
  Cancelof
- Today's Date:*
  
  MonthDayYear
  Date
  Hour MinutesAM/PM Option
- Should be Empty: