PARTIAL HAND SILICONE INTERFACE ONLY

  • 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.

  • PARTIAL HAND SILICONE INTERFACE ONLY

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

    • 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.

    • All Requirements need to be met before you can proceed. 

  • PARTIAL HAND SILICONE INTERFACE ONLY

    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.
    • Design: 
    • M Fingers: 
    • Titan Fingers: 
    • Point Design: 
    • Static Bio-Identical: 
    • Silicone Only: 
    • Finishing: 

  • PARTIAL HAND SILICONE INTERFACE ONLY

    Notes
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  • Daily HFN Capacity

  • {requestedInoffice}{requestedInoffice1811}{requestedInoffice1812}{requestedInoffice1813}

    • Requested In-Office Date: 
    • Image field 1816

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

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  • Should be Empty: