Health Related Products: Nose Prosthesis Order Form

Health Related Products - "your special needs provider"

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 a Nose Prosthesis:
1.	In the case of a total amputation, it is extremely important to estimate the measurements of the original nose and its configuration
2.	If possible, provide close-up photographs of the patient which were taken prior to the amputation. The use of photographs is the best method by which to duplicate the original nose
3.	The accuracy of detail picked up in the cast will determine the degree of proper fit and the patient's ultimate satisfaction with the restoration. Refer to the Realastic Handbook for basic methods and techniques.
4.	Indicate all measurements in millimeters.
5.	In addition to the information that is required on this chart, please include any additional information that will assist the sculptor, such as comparative drawings.

Anatomy of the Nose:

Please Specify all measurements in millimeters:
1. Profile Length: *
2. Profile Depth: *
3. Front Width: a. nasal bone: * b. alar cartilage: *
4. Profile Contour: *
5. Angle of Septum: *
6. Color of Nose 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

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