Health Related Products: Foot Extremity Information Chart

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:	*
Prosthesis:	*

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

Remember:

We cannot see the patient; this information is the only means we have to know what they need. Please be as thorough and accurate as possible with all of your information. We are not responsible for any incorrect information given on these charts. Also, check your casts for accuracy, we use them to match and fit the prostheses.

Reference drawings:

Please Specify all measurements in inches:
1. Zipper:(vinyl only)	*
2. Zipper length:	* up to 3", not to extend beneath heel
3. Carbon Fiber Sole Reinforcement:
4. Half Moons are:	*
5. Knuckles are:	*
6. Veins are:	*
7. Requested height from heel to top of prosthesis (up to 4"):	*
8. Length from great toe to heel	*
9. Width from A to B (see drawing):	*
10. Shoe sample enclosed:	*
11. Color from R-issue (vinyl) or K-series swatch (silicone):	* Note: 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
11. Special Instructions: