TRANSHUMERAL DEFINITIVE SOCKET

  • Legacy form will no longer be accepted.

  • Access Legacy PDF work orders below. Legacy form will be accepted until Mar 4th. 

    Transhumeral External Powered Transhumeral Body Powered Transhumeral Hybrid

  • Please do not print the Review page.

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

  • TRANSHUMERAL DEFINITIVE SOCKET

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

    • Bilateral Symmetrical: 

      • Left and Right sides can have different Measurements
      • Same Alignment, Design and Finishing options
    • Weight Unit:
    • Scan being submitted with order: (Deprecated-Do Not Delete)*

    • Upload Scan at the end. 

    • Submission Type:

      • Diagnostic Socket

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

    • Your order will be sent to CDC after submission. 

    • Date:*
       - -
    • Is this a Hanger3D app scan?*
      • 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

        

    • Scan Type:*

    • 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.

  • TRANSHUMERAL DEFINITIVE SOCKET

    Device Type
  • Device Type:

  • TRANSHUMERAL DEFINITIVE SOCKET

    Configurator

  • NOTE TO CLINICIAN

    It is strongly advised that ALL external powered devices be sent to fab in a trial fitting setup with all components aligned and tested for operation. Include TD & chargers with the setup.

  • 0/250
    • Measurements: 
    • Please indicate measurement unit:*

    • Best Practice  - Hand closed, thumb in lateral/key grip–side of index finger

    • Length Measurement from:*
    • Length Measurement to:*
    • Length Measurement to:*

    • Adjustments to Diagnostic Set up:

    • Length:
    • Section:*
    • Go by:*
    • Patient Measurements
    • Alignment: 

    • i

      NEUTRAL is the Tibia perpendicular to the floor based on Heel Height. 

    • Alignment:*

    • Standard Alignment:

      • Elbow perpendicular to the Socket
    • Elbow Sagittal Alignment:*

    • Final Elbow Position:

    •    *      degrees from current position.                              

    • Elbow Coronal Alignment:*

    • Final Elbow Position:

    •    *            degrees from current alignment.

    • Elbow Linear Shifts:

    • Final Elbow Position:

    •     *        *in from current position.

    •     *        *cm from current position.

    •     *        *in from current position.

    •     *        *cm from current position.

    • Materials/Design: 
    • Components to be ordered by:*
    • Socket Design:*
    • External Powered: 
    • Harness:*

    • Standard Harness:

      •  Chest strap (Details in Notes)
    • Harness Options:

    • Electronics:

    • Control System:*
    • Traditional Control System:*
    • Sites:*
    • Electrodes:*
    • Style:*
    • Switch/Linear Pot included:*
    • Battery:*
    • Battery Capacity:*
    • Battery Style:*
    • Wrist:*
    • Rotator/Lamination Coupler:*
    • Quick Disconnect:*
    • Body Powered: 
    • Cabling:*

    • Standard Cabling:

      • Spectra with Teflon
      • Ball terminal & hanger attached
      • TRS ferrule in housing
      • Plastic covering over housing
      • Leather lift assist

    • Cabling Options:
    • Harness:*

    • Standard Harness:

      • Fig. 8 with Large NW ring
      • Four-Bar buckles
      • Anterior elastic strap and 1/2" Dacron for elbow lock
      • Lateral support anterior to acromion
    • Harness Options:
    • Hybrid Powered: 
    • Cabling:*

    • Standard Cabling:

      • Spectra with Teflon
      • Hanger attached
      • TRS ferrule in housing
      • Plastic covering over housing
      • Leather lift assist or directly to forearm (OB)

    • Cabling Options:
    • Harness:*

    • Standard Harness:

      •  Fig. 8 with Large NW ring
      • Four-Bar buckles
      • Anterior elastic strap and 1/2" Dacron for elbow lock
      • Lateral support anterior to acromion
    • Harness Options:

    • Electronics:

    • Control System:*
    • Traditional Control System:*
    • Sites:*
    • Electrodes:*
    • Style:*
    • Switch/Linear Pot included:*
    • Battery:*
    • Battery Capacity:*
    • Battery Style:*
    • Wrist:*
    • Rotator/Lamination Coupler:*
    • Quick Disconnect*
    • Suspension: 
    • Suspension Options:*
    • Valve:*
    • Image field 1299
    • Image field 1294
    • Image field 1295
    • Image field 1438

    • i

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

    • Inner Socket:

    • Material:*
    • Finished Flexible Thickness:*
    • Anchor Placement/Quantity:*

    • Standard Anchor Placement/Quantity:

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

    • Outer Frame:

    • Elbow Options:
    • Finish:*
    • Amount of Inner Liner Exposed:*

  • TRANSHUMERAL DEFINITIVE SOCKET

    Notes

  • 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

      

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  • Patient Gender:*
  • Who would you like a call from?*
  • 0/250
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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}{requestedInoffice1573}{requestedInoffice1574}{requestedInoffice1575}

    • Requested In-Office Date: 
    • Image field 1578

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

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