- Ottobock
Company C-Brace Account # Order Form Practitioner Please mail your completed Ottobock order form and a negative impression of the patient’s limb to the address below. An Ottobock Fabrication Coordinator will contact you. Mailing Address Phone Fax Shipping Options: Email Address UPS Next Day Patient Name PO Number Requested Due Date Cooperative Care Yes All specifications and pricing are subject to change without notice. ©2015 Otto Bock HealthCare LP • 13205 • 4/15 Left Right UPS Ground Other ______________ Date of Submission No 3 Phase Casting Technique Required. For clinical questions call 800 328 4058. Note: Training Required. Specify UPS 2–Day Special Instructions/Comments Patient Weight _____________________ Measurements in Centimeters Only Spring Element Fiberglass (220 lbs weight limit) Carbon (275 lbs weight limit) Fitting Stage Test-Orthosis (Test Orthosis will be provided with locked Knee Joints and Multifunctional Ankle Joint) Lateral Trim Line to bottom of heel Medial Trim Line to bottom of heel Prepreg C-Brace Orthosis Definitive Options Straps and Tongues Standard Configuration—2 Thigh Straps and Tongue, 1 Calf Strap and Tongue Additional Strap(s) Specify _____________________ Additional Tongue(s) Specify ____________________ Specify Tongue Type: Floating Attached Liner Options (includes 2 sets) Space-Tex (Black) Terry Cloth (Blue) Bock Lite Microcell Puff Corrective Pads Medial Thigh 3mm 4mm Medial Calf 5mm 6mm Knee Center Line to bottom of heel AirFlex (Black) Other __________________ Finish Finished satin carbon design Ankle Center Line to bottom of heel Fabric Design, specify _____________________ Bottom of Heel (if any) Foot Casting Aid cm Ottobock Fabrication Services 1130 S. 3800 West, Ste. 400, Salt Lake City UT 84104 For more information please visit our web site at www.ottobockus.com Page 1 of 1 USA 800 328 4058 Fax 800 810 7994 Email [email protected]
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