Health Related Products: Ear Prosthesis Order Form

NOTE: This is NOT a secure site. We do not recommend you use a patient's name, but rather an identification code to comply with HIPAA regulations.
Information marked with an asterisk ( * ) is required.
You may tab to move between fields.

Patient Information
Identification:	*
Age:	*
Sex:	*
Weight:	(specify lbs. or kg)
Height:	(specify in. or cm)
Side:	*

Customer Information
Name:	*
Address 1:	*
Address 2:
City:	*
State:	*
Zip:	*
Country:	if not USA
PO #:
Account #:
Phone:	* (###-###-####)
e-mail:

Requirements for an Ear Prosthesis:
1.	Casts taken of both the sound ear and the amputation seat must be exact duplications. The accuracy of detail picked up in the cast will determine the degree of proper fit and the patient's ultimate satisfaction with the completed prosthesis. Refer to the Realastic® Handbook for basic cast-taking methods and techniques.
2.	Include close-up color photographs of the sound ear from the back, front, and side.
3.	Please include any additional information not requested that will assist the sculptor in creating the prosthesis.

Anatomy of the External Ear:

Please Specify all measurements in millimeters:
1. Frontal Profile: a. Greatest distance that helix extends out horizontally from the head (measured on the posterior side of the ear): * b. Greatest distance that the top of the helix extends out from the head: *
2. Side Profile: a. Greatest width of ear from anterior to posterior (measured horizontally from the anterior base of tragus to the farthest edge of the helix): * b. Greatest length of the ear from the bottom of the lobe to the top of the helix: *
3. Angle of Sound Ear: *
4. Color of the Ear from K-series swatch: *	Select color that is one shade lighter than required to match patient's skin tone. Final matching of the patient's skin tone is best performed after you receive the prosthesis
5. Additional Instructions: