AMPUSHIELD® TRANSRADIAL LIMB PROTECTOR

  • 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 Mar 4th. 

  • Legacy form will no longer be accepted.

  • AMPUSHIELD® TRANSRADIAL LIMB PROTECTOR

    Intake Information
  • Format: (000) 000-0000.
    • Patient Information: 

    • The Shipping section is now at the end of the form.

    • Submission Type:

      • Physical Device

        Please include a printed Work Order with the device when shipping.

  • AMPUSHIELD® TRANSRADIAL LIMB PROTECTOR

    Configurator
    • Measurements: 
      • Small/Large - Not Available
    • Image field 1739
    • Image field 1747
      • Adjust to patientʼs length with distal pad as needed.
      • Device will be shipped with 2" distal end pad that is split in half.
    • Device: 

  • AMPUSHIELD® TRANSRADIAL LIMB PROTECTOR

    Notes
  • 0/1000
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  • Daily HFN Capacity

  • {requestedInoffice}{requestedInoffice1768}{requestedInoffice1769}{requestedInoffice1770}

    • Requested In-Office Date: 
    • Image field 1773

    • Clinicians can still coordinate special in-office requests by emailing:
      HFN_Hypercare@hanger.com

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  • Should be Empty: