Workorder #:
Orlando Ph 407.852.6170 | Fx 407.852.6171
[email protected]
Charleston Bending Brace
(Lab Use Only)
PO / OPS:
Bill To:
Address:
Patient Name:
Height:
Weight:
Age:
Same as Bill to
Ship To:
Pt is a previous
CBB wearer
Male
Female
Other Brace Type:
Address:
Compliance Monitor (1/4" foam only):
Email:
Phone #:
YES
NO
In-Office Request Date:
CBB II-Dynamic Lumbar Pad
CBB-Standard
am
pm
IMPORTANT INSTRUCTIONS
• All measurements must be taken and completed on this order form
• X-rays must be sent or a digital images are preferred
STANDARD COLORS
(Choose One)
Natural
Light Pink
Light Blue
Friddles Transfer (extra charge)
Number:
[email protected]
In the Subject Line: Charleston Bending Brace or CBB
• Complete information is required for manufacturing
Description:
MEASUREMENTS IN INCHES ONLY
Measurements taken
SELECT TYPE
OF TREATMENT
OR
PROVIDE
MAJOR CURVE
CBB-1
CBB-2
CBB-3
CBB-4
CBB-5
LT
RT
Double
Lumbar
Thoracic
Thorocolumbar
COBB ANGLES:
(limits & magnitudes)
LORDOSIS
BRACE
Thoracic
Lumbar
Supine
Supine
Circ.
M/L *
A/P *
Axilla
BEND TO
Right
Xyphoid
Left
2” above waist
Waist
ASIS
Apex
Apex
Gluteal Fold/
Trochanter
Supine mx:
In brace:
Standing
* M/L & A/P measurements taken with a M/L mx stick (not a tape measure)
10°
20°
Other:
(In brace 0° if not otherwise specified)
SPECIAL INSTRUCTIONS:
°
Linear mx:
Supine
Axilla
Xyphoid
Waist
Standing
Thoracic Height
T
Finished Length
Gluteal Fold
(Finished Length)
(All length measurements will be used to determine finished trims)
Practitioner (print name):
Signature:
(Must be signed by a CBB Certificate holder only)
CBB Certification Number:
CBB
NL_2014_R2