TEMPLATES
AK by Measurements
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*P.O. #
*Company/Branch:
Address:
City:
State:
Zip:
*Phone #:
*Shipping Method:
*E-mail:
*Contact Name:
PATIENT INFORMATION
Patient Name:
Sex:
*Activity Level:
MEASUREMENTS
DISTAL END
*Choose One:
Level
Reduced
measurements
for suction:
0"
2"
4"
6"
8"
10"
12"
*All measurements in inches
M-L of distal end:
Knee disarticulation
**We fabricate our products from the measurements you provide, to the specifications requested, and in accordance with generally accepted O & P industry practices. We rely entirely upon the judgment and evaluation of the qualified professional seeing the patient to ensure the fit and function of our products and will make every effort to rectify any situation that may arise.
SPECIAL INSTRUCTIONS
CONTACT INFORMATION
Online Ordering
Length:
Flexion:
Adduction:
OTHER INFORMATION
110 Industrial Road
Fulton, MO 65251800.470.1188
Fulton, MO 65251800.470.1188*
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My Custom
template:
