TRANSHUMERAL DIAGNOSTIC SOCKET

Legacy form will no longer be accepted.

Access Legacy PDF work order. Legacy form will be accepted until Mar 4th.

Please do not print the Review page.

Scroll to the bottom, hit Complete and then download the work order.

Please enter to receive confirmation.

Please enter a valid phone number.Format: (000) 000-0000.

Symmetrical (Single Work order)Asymmetrical (Separate Work orders for each side)

Bilateral Symmetrical:

Left and Right sides can have different Measurements
Same Alignment, Design and Finishing options

Upload Scan at the end.

Submission Type:

Plaster Cast: Negative or Positive

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

Your order will be sent to CDC after submission.

Modified Plaster Positive

Previous Model Order Date

Please complete this form. Next, after acquiring the scan via the Hanger3D app, go to Order Forms > Jotform Order and fill out the required information and submit the scan. NO OTHER ACTION IS NEEDED

Outside Cast Scan (preferred)Positive Model: UnmodifiedPositive Model: Modified

The Cast Measurement fields are available at the end of the Form.

Due to the scan being modified, the Alignment and Modification options will not be displayed.

Any Alignment or Modification changes can be called out in the Notes section.

Since the Positive plaster model is already modified, the Alignment and Modification options will not be displayed.

Any Alignment or Modification changes can be called out in the Notes section.

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

U9810-TH/ED TEST SOCKET/FRAMEU7616-TH/ED SILICONE TEST SOCKET OR LINER

FLEXIBLE/SILICONE ONLYRIGID FRAME

ImpressionMeasurements

Decimal value optional

NoneValveLockPull Hole

Distal Medial (Standard)Other

RV Slide ValvePee Wee Valve (Valve and Threaded Housing)LYN ValveOther

Icelock 721 RatchetOther

Finshed Plastic thickness will be within 10% of requested thickness.

1/8" (3 mm)3/16" (5 mm)

Standard Anchor Placement/Quantity:

4 Anchors
Location:
- 1 Anterior Wing
- 1 Posterior Wing
- 1 Proximal Axilla
- 1 Distal Lateral

Enter the quantity as a number

Describe Anchor location (50 character limit)

3/32" (2 mm)1/8" (3 mm)5/32" (4 mm)3/16" (5 mm)

Your order will be sent to CDC after submission along with the Scan. No futher action is needed.

(No Entry required at the LEO portal)

Your order will be sent to CDC after submission. No futher action is needed.

(No Entry required at the LEO portal)

Please complete this form. Next, after acquiring the scan via the Hanger3D app, go to Order Forms > Jotform Order and fill out the required information and submit the scan. NO OTHER ACTION IS NEEDED

Accepted File types: med, fsn, op3, stl - 60 MB File Size Limit

Decimal Value Optional

Modifications (Modifier)Design options on device (Fab Supervisor)Shipping/Billing (Customer Support)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Order ship date may be impacted by incomplete order, component availability and upon cast receipt (for physical orders).

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

Date

Hour MinutesAM/PM Option

TRANSHUMERAL DIAGNOSTIC SOCKET