AMPUSHIELD® TRANSHUMERAL 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® TRANSHUMERAL LIMB PROTECTOR

    Intake Information
  • Format: (000) 000-0000.
    • Patient Information: 
    • Affected Side:*
    • Bilateral:*
    • Bilateral Type:*
    • Weight Unit:

    • 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.
    • Raven Base Code:
    • Device Type:

  • AMPUSHIELD® TRANSHUMERAL LIMB PROTECTOR

    Configurator
  • Please indicate measurement unit:*
    • Measurements: 
    • Ampushield Size:*
      • Small - Not Available
    • Image field 1739
    • Image field 1747
    • Image field 1769
      • Adjust to patientʼs length with distal pad as needed.
      • Device will be shipped with 2" distal end pad that is split in half.
    • Device: 
    • Options:

  • AMPUSHIELD® TRANSHUMERAL LIMB PROTECTOR

    Notes
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  • Return Shipping Method:
  • Shipping is same as Billing Address:*
  • Requested In-Office Date:
     - -
  • Requested In-Office Date:
     - -
  • Requested In-Office Date:
     - -
  • Requested In-Office Date:
     - -

  • Daily HFN Capacity

  • {requestedInoffice}{requestedInoffice1775}{requestedInoffice1776}{requestedInoffice1777}

    • Requested In-Office Date: 
    • Image field 1780

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

    • Today's Date:*
       - -
  • Should be Empty: