19.02.2019 Ossur Evolution Custom Liner Form
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Activity Level: 3 4 2 1 Amputation Level: Right: Left: BK SYME AK KD Patient Name/Reference: Weight: Completion of this order form with the most accurate and up-to-date information, including all patient information, measurements, and construction information enables us to provide the highest quality product for you and your patient. PO#: Shipping Check Priority: 2nd Day ($8 Flat Rate) Next Day Air Company: Address: City/State/Zip: Contact: Phone: Email: Bill To: Company: Address: City/State/Zip: Contact: Phone: Email: Ship To: Date Needed in Office: Össur Account #: IF YOU DON’T HAVE AN ÖSSUR ACCOUNT #, PLEASE FILL OUT FIELDS BELOW MPT to Floor KC to Floor IT to Floor BK 12 10 8 6 4 2 MPT 0 2 4 6 8 10 12 AK 0 2 4 6 8 10 Length of Limb: * Please cast or scan as high as you would like the liner to be in length. ** Length and circumferences required. If not provided and liner fit requires remake, customer is responsible for cost of remake. MEASUREMENTS Negative Cast Positive Cast AOP File LINERS ADD WAVE Recommended for TT liners EVO110 EVO310 EVO210 EVO410 Item # Description EVO110-W EVO310-W EVO210-W EVO410-W Item # NOTES LINER DESIGN mm LINER OPTIONS LINER PROFILE 13 mm: Cushion 21 mm: Locking 6 mm: KD, SYMES 6 mm 3 mm Distal Thickness Base Proximal Standard Design Add Distal Thickness Natural / No silking agent (liner is tacky inside and outside) Matrix Proximal Lateral Attachments Fill Invagination Stovepipe BILLING & SHIPPING INFORMATION EVOLUTION TRULY CUSTOM LINER ORDER FORM © 2019 ÖSSUR, INC. E-072315, 1.00 SEND ALL CASTS, SOCKETS, AND FILES TO: 7199 S CONWAY RD #100 | ORLANDO, FL 32812 TEL (888) 839-6213, FAX (800) 788-9878 | [email protected] PATIENT INFORMATION CONSTRUCTION *ITEMS IN BOLD ARE THE DEFAULT SELECTIONS UNLESS OTHERWISE SPECIFIED New Evolution Silk Custom Cushion Liner Additional Evolution Silk Custom Cushion Liner New Evolution Silk Custom Locking Liner Additional Evolution Silk Custom Locking Liner Molds retained for two years after last liner order. Two years after last liner order mold will be destroyed.
Transcript of 19.02.2019 Ossur Evolution Custom Liner Form
Activity Level: 3 421Amputation Level: Right:Left:BK SYME AK KDPatient Name/Reference: Weight:
Completion of this order form with the most accurate and up-to-date information, including all patient information, measurements, and construction information enables us to provide the highest quality product for you and your patient.
PO#: Shipping Check Priority: 2nd Day ($8 Flat Rate)Next Day Air
Company:
Address:
City/State/Zip:
Contact:
Phone: Email:
Bill To:Company:
Address:
City/State/Zip:
Contact:
Phone: Email:
Ship To:Date Needed in O�ce:Össur Account #:
IF YOU DON’T HAVE AN ÖSSUR ACCOUNT #, PLEASE FILL OUT FIELDS BELOW
MPT to Floor
KC to Floor
IT to Floor
BK
12
10
8
6
4
2
MPT 0
2
4
6
8
10
12
AK
0
2
4
6
8
10
Length of Limb:
* Please cast or scan as high as you would like the liner to be in length.** Length and circumferences required. If not provided and liner �t requires remake, customer is responsible for cost of remake.
MEASUREMENTS
Negative Cast
Positive Cast
AOP File
LINERSADD WAVE
Recommended for T T l iners
EVO110
EVO310
EVO210
EVO410
Item # Description
EVO110-W
EVO310-W
EVO210-W
EVO410-W
Item #
NOTES
LINER DESIGN
mm
LINER OPTIONSLINER PROFILE
13 mm: Cushion 21 mm: Locking 6 mm: KD, SYMES
6 mm
3 mm
Distal Thickness
Base
Proximal
Standard Design
Add Distal Thickness
Natural / No silking agent
(liner is tacky inside and outside)MatrixProximal Lateral Attachments
Fill InvaginationStovepipe
BILLING & SHIPPING INFORMATION
EVOLUTION TRULY CUSTOM LINER ORDER FORM
© 2019 ÖSSUR, INC. E-072315, 1.00
SEND ALL CASTS, SOCKETS, AND FILES TO: 7199 S CONWAY RD #100 | ORLANDO, FL 32812TEL (888) 839-6213, FAX (800) 788-9878 | [email protected]
PATIENT INFORMATION
CONSTRUCTION *ITEMS IN BOLD ARE THE DEFAULT SELECTIONS UNLESS OTHERWISE SPECIFIED
New Evolution Silk Custom Cushion Liner
Additional Evolution Silk Custom Cushion Liner
New Evolution Silk Custom Locking Liner
Additional Evolution Silk Custom Locking Liner
Molds reta ined for t wo years af ter last l iner order. Two years af ter last l iner order mold wi l l be destroyed.
