TF COMPLETE LEG ORDER FORM PACKAGE

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Adelia Harmon
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1 TF COMPLETE LEG ORDER FORM PACKAGE Thank you for ordering a TF Complete Leg from Össur Custom Solutions. This package includes all the order forms needed to define the transfemoral leg, order the check socket and then order the definitive socket. STEP ONE: ORDER THE COMPLETE LEG AND CHECK SOCKET Complete the TF Complete Leg Order Form and send to Össur Custom Solutions via fax or . If you want the liners sent first so you can cast or scan over the new liners, please check the box next to Liners in the Products Section. Össur Custom Solutions will then create and send you a quote detailing all items in the Complete Leg. Approve the quote and provide a purchase order number to finalize the order. Measure the residual limb. VIA PAPER VI A ÖS S UR C US TOM S OL UTI ONS I PAD APP Cast over the same type and size liners the amputee will use. Complete the Measurements section of the attached TF Complete Leg Order Form. Send cast and TF Complete Leg order form to Össur Custom Solutions (see form for address). Input measurements in the Össur Custom Solutions app. For knee disartic sockets, scan over the same type and size liner the amputee will use. Send the order to Össur Custom Solutions via the app. STEP TWO: FIT THE CHECK SOCKET, MAKE ANY NECESSARY MODIFICATIONS STEP THREE: ORDER THE DEFINITIVE SOCKET Fill out the attached TF Complete Leg Definitive Socket Order Form. Send TF Complete Leg Definitive Socket Order Form and modified check socket to Össur Custom Solutions (see form for address). This form is available in electronic form you can fill out electronically and or print. Please contact Össur Customer Service for a copy. page 2 of 2 FOLLOW ÖSSUR ON ÖSSUR, ÖSSUR ORLANDO PH: FAX: CS@OSSUR.COM 7199 S CONWAY RD #100 ORLANDO, FL 2812

2 TF COMPLETE LEG ORDER FORM Send all casts, sockets, files to: 7199 S Conway Rd #100, Orlando, FL 2812 tel: (888)89-621, fax: (800) cs@ossur.com AREA MANAGER INFORMATION Area Manager: phone: Notes: BILLING & SHIPPING INFORMATION Össur Account #: Date needed in office: Ship To: Company: CONTACT FOR ORDERING OR DELIVERY QUESTIONS: Address: City/State/Zip: Fax: Shipping Check Priority: PO#: Next Day Air 2nd Day 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. REQUIRED PATIENT INFORMATION Last Name: Height: First Name: Weight: ft. Impact Level: High in. K-Level: K1 lbs. K2 Med K Low K4 Amputation Level: TF Left: Right: KD Bilat Order: MEASUREMENTS ME AS U R E M E N T S* * IT to Floor KC to Floor Length: Level Tight* cm 10cm Soft IC BR I M IC 2cm 0cm Conical Loose* L I NER US ED *ANGL ES Flexion: Adduction: *Expulsion and vacuum angles are if not specified. 1cm 20cm DI S TAL END S HAPES Squared Bulbous Cylindrical Quad Total Reduction: % Cast sent to Össur Custom Solutions (optional) Ply Check here to receive foam carving for this order. *No reduction when tight and loose measurements provided. **Length and circumferences are required. If not provided and socket fit requires remake, customer is responsible for cost of remake. NOTES MPT to Floor Next page 1 of

TF COMPLETE LEG ORDER FORM PRODUCTS 1: ASSEMBLY ( check one) Note: Customer responsible for torque and Loctite on all check leg screws and bolts distal to Össur socket adapter Partial Assembly:

3 TF COMPLETE LEG ORDER FORM PRODUCTS 1: ASSEMBLY ( check one) Note: Customer responsible for torque and Loctite on all check leg screws and bolts distal to Össur socket adapter Partial Assembly: Customer cuts pylon to final height (default option) Full Assembly by Össur (landmark to floor measurement required) Full Assembly by Customer (reduces socket turnaround time by 2 days) 2: LINERS (check one then fill in desired sizes and options) LO C K ING OPT ION S Send liners first for casting SE A L-I N OPTI ONS liner size liner size ring size standard conical TF Locking Seal-In X TF w/ring Seal-In X TF Seal-In TF 4Seal Classic standard conical : SOCKETS (check options) No Check Socket PETG Check Flexible Inner Thermolyn Check Flexible Inner Laminated Definitive Flexible Inner 4: SUSPENSION & SOCKET ADAPTER (check all that apply) LO C K ING OPT ION S Works With 600 Series Ratchet Lock & Extra Pin 600 Series Smooth Lock & Extra Pin 600 Series 4 Hole 600 Series Pyramid Adapter EXP U L S ION OPT IO N S 200 Series Lock & Extra Pin UNI TY OPTI ONS Expulsion Plate Kit AK Icelock Expulsion Valve Unity Plate Kit Works With 44 Socket Adapter -Prong 4-Prong Unity Valve Kit LA NYAR DS Icelock 600 Series Lanyard OTHER OPTI ONS (write in) Icelock 200 Series Lanyard Other: Next page 2 of

TF COMPLETE LEG ORDER FORM PRODUCTS (CONTINUED...) *Locking knee cables will be installed on the anterior/lateral section of the check/definitive socket unless otherwise requested in the Notes section.

Extension Assist Option 2000 + A-800 Total Knee 2000 w/ Pyramid Top Extension Assist Option MKN7160 Mauch Knee OH OP4 OP OHP RKN1000 RHEO KNEE RKNXC000 RHEO KNEE XC 6: FOOT: WITH OR WITHOUT UNITY

4 TF COMPLETE LEG ORDER FORM PRODUCTS (CONTINUED...) *Locking knee cables will be installed on the anterior/lateral section of the check/definitive socket unless otherwise requested in the Notes section. : KNEE (check one) LKN1200 Locking Knee BKC1200 Balance Knee Control BKN1200 Balance Knee BKN1211 Balance Knee Locking BALANCE KNEE OFM1 BALANCE KNEE OFM A800 Total Knee 1900 w/ Pyramid Top Extension Assist Option A-800 Total Knee 2000 w/ Pyramid Top Extension Assist Option MKN7160 Mauch Knee OH OP4 OP OHP RKN1000 RHEO KNEE RKNXC000 RHEO KNEE XC 6: FOOT: WITH OR WITHOUT UNITY (check one and fill out the options below) FOOT OPT IONS Foot Size: cm. Category (1-9): Left: Right: Foot Shell: Beige Brown PROPRIO PROPRIO Pro-Flex Pro-Flex Pro-Flex XC Pro-Flex XC Pro-Flex XC Torsion Pro-Flex XC Torsion Pro-Flex LP Pro-Flex LP Pro-Flex LP Torsion Pro-Flex LP Torsion ReFlex Shock ReFlex Shock ReFlex Rotate ReFlex Rotate Variflex Variflex Talux Assure Assure Balance J Balance J K2 w/ DP Flexion K2 w/ DP Flexion K2 Sensation K2 Sensation FOLLOW ÖSSUR ON ÖSSUR, ÖSSUR ORLANDO PH: FAX: CS@OSSUR.COM 7199 S CONWAY RD #100 ORLANDO, FL 2812 Print Next

5 TF DEFINITIVE SOCKET ORDER FORM BILLING & SHIPPING INFORMATION Össur Account #: Date Needed in Office: Ship To: Company: CONTACT FOR ORDERING OR DELIVERY QUESTIONS: Address: City/State/Zip: PO#: Shipping Check Priority: Next Day Air 2nd Day 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. PATIENT INFORMATION Last Name: Impact Level: High Medium First Name: Amputation Level: TF Low DEFINITIVE SOCKET Left: KD Weight: Right: Bilat Order: lbs. *ITEMS IN BOLD ARE THE DEFAULT SELECTIONS UNLESS OTHERWISE SPECIFIED T F ME AS U R E M E N T C H A R T From Socket From Cast From CAD/AOP file dated: FABR I C ATI ON IT to Floor KC to Floor S OC KET M ATER I AL S PEC I AL FABR I CATIO N INNER LAMINATION FINISH Carbon Proflex MPE Color (PRS Pigment 1-16)* Keasy Decorative Lamination* Other RevoFIT Socket (draw windows and dial location on check socket) Pads on RevoFIT panels Cosmetic Cover (see left) * Torque and Loctite all screws and bolts in Össur components. **We will remove and return any alignment adapters you added unless you specify in Notes for us to reattach them. CUSTOMER NOTES A L IG NME NT Transfer Modify MOD IF I C AT I O N S S O CKE T S IZING P R O ST H E T I C H E I G H T Increase Decrease %: Ply: Transfer Extend: Shorten: SEND ALL CASTS, SOCKETS, AND FILES TO: 7199 S CONWAY RD #100 ORLANDO, FL 2812 TEL (888) , FAX (800) CS@OSSUR.COM ÖSSUR, INC. E , 1.14 Print

6 ÖSSUR CUSTOM SOLUTIONS DELIVERY TIMES TO 48 US STATES Socket Delivered to Customer* Description Assembled Leg Delivered* Complete Leg Extra Charge (no discounts) Create electronic shape by cast AK PETG Check Socket AK PETG Check Socket >2 Circumference and 16 Length AK Thermolyn Check Socket AK Thermolyn Check Socket > 2 Circumference and 16 Length AK Laminated Definitive Socket NU-FlexSIV AK Definitive - - BK PETG Check Socket BK Thermolyn Check Socket BK Laminated Definitive Socket *Day 0 is when Össur Custom Solutions has received before noon customer s time approved quote, purchase order number, completed order form with measurements, plus scan, cast, or check socket. *Customer pays for shipping to Össur Custom Solutions and shipping time to Össur not in quoted delivery times. ADDITIONAL TIME FOR CERTAIN OPTIONS Don t add time for each option, take the longest time for your selected options. Socket Delivered to Customer* Description Customer-Supplied Decorative Socket Graphics, External and/or Internal on Definitive** Ossur-Supplied Decorative Socket Graphics, External and/or Internal on Definitive** Add Single Lamination AK AK Foam Cover AK Flex Polyethylene in Socket AK Proflex with Silicone AK Proflex without Silicone AK P-Lite Inner AK Keasy Cone Inner Add Single Lamination BK BK Flex Polyethylene in Socket BK Proflex w/silicone Inner Socket BK Shape Foam Cover BK Finish Lamin Removable Cover BK Symes Door - Laminated BK Symes Door - PETG BK Keasy Cone Inner Add RevoFit BK P-Lite Inner FOLLOW ÖSSUR ON 2017 ÖSSUR, INC. E , 1.01 Assembled Leg Delivered* Complete Leg Extra Charge (no discounts) TBD TBD no additonal 2 add on def only 2 add on def only 2 add on def only 1 add on top of time for any other options 1 add on top of time for any other options ÖSSUR ORLANDO 7199 S CONWAY RD #100 ORLANDO, FL 2812 TEL (888) , FAX (407) CS@OSSUR.COM

PRO-FLEX XC TORSION ÖSSUR IMPACT SOLUTIONS

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