BioStride Series BioStride Series Product Orders For expedited processing of new product orders, please complete this form and submit it by fax to 661.864.7512, or scan this document and E-mail it to [email protected]. For verbal orders, please call 661.325.3338. Patient Name ___________________________________ Select BioStride Series Model Patient Profile Male Female Which definition best describes this patient? New Amputee 1-3 Year Amputee 4+ Years Amputation Level: Amputation Side: AK Left BK Right Base Code Recommendation: L-5987 Code: L-5986 or L5984 Optional Male Pyramid Build Height Clearance: 7 5/16” Female Pyramid Build Height Clearance: 7 11/16” Bilateral Age: _________ Height: __________ Weight: _________ Foot Length: _______ cm Shoe Heel Height: ___________ (Keels available in 22-31cm) (Maximum heel height 1 1/4”) Foot Shell Light Flesh Tone UltraStride (bifurcated shank) K3: 70-310 lbs. & K4: 70-265 lbs. Dark Flesh Tone Everyday Routine Activity Level (please select one) K2 (variable cadence, navigates most moderate environmental barriers) K3 (variable cadence, navigates environmental barriers including stairs, steps, inclines, and declines, uneven terrain) K4 (variable cadence, navigates environmental barriers including running, hiking, skiing, tennis, bicycling) K4 Extreme (variable cadence, navigates environmental barriers including lifting/pushing heavy loads or high impact activities. This includes weight lifting, cross training, construction work, basketball, soccer, motocross) If we have a question regarding this order, please provide the name/number of the person we should contact: PO # ____________________________________________ ActiveStride K3: 70-310 lbs. & K4: 70-265 lbs. Base Code Recommendation: L-5980 Optional Code: L-5986 or L5984 Male Pyramid Build Height Clearance: 7 5/16” Female Pyramid Build Height Clearance: 7 11/16” NaturalStride (bifurcated shank) K3: 70-500 lbs. & K4: 70-385 lbs. Base Code Recommendation: L-5981 Optional Code: L5986 or L5984 Male Pyramid Build Height Clearance: 5 7/8” Female Pyramid Build Height Clearance: 6 1/4” K2 ComfortStride K2: 70-500 lbs. Base Code Recommendation: L-5972 Optional Code: L-5986 Male Pyramid Build Height Clearance: 5 7/8” Female Pyramid Build Height Clearance: 6 1/4” Select Pyramid (Not rotation adjustable) Male Female Practitioner: ______________________________________ Phone: __________________ Fax: __________________ Email: _________________________________________ Additional Accessories (Additional charges apply) Light Flesh Tone Foot Shell Dark Flesh Tone Foot Shell Foam Calf Shank Cover (8-inch length) Additional Spectra Sock ___1 ___ 2 ___ 3 Bill To: Company Name: ___________________________________ Shipping Preference (Additional charges apply) Ground 3 Day 2 Day Next Day (If no preference is indicated, products will ship UPS ground) Street Address: ____________________________________ City: _____________________State:______ Zip: _________ Ship To: (complete this section if different from billing address) Company Name: ___________________________________ Street Address: ____________________________________ 45 Day Risk Free Evaluation Period and Warranty Coverage Makstride Prosthetics offers a 45 day unrestricted return policy for risk free comparison and evaluation. If you or the patient are not satisfied with the performance and functional benefits of the foot, you can seek assistance from Makstride Prosthetics staff to achieve the desired outcome, or return the product for credit. NO REFUNDS AFTER 45 DAYS. 36 month repair/replacement warranty (please refer to warranty/return documents for qualifications.) City: _____________________State:______ Zip: _________ Makstride Prosthetics – 3970 South 1540 East, St. George, Utah, 84790 Phone: 661.325.3338 Fax: 661.864.7512
© Copyright 2024