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
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USA 800 328 4058
Fax 800 810 7994
Email [email protected]