19.02.2019 ossur evolution custom liner form

Activity Level: 3 421Amputation Level: Right:Left:BK SYME AK KDPatient Name/Reference: Weight:

Completion of this order form with the most accurate and up-to-date information, including all patient information, measurements, and construction information enables us to provide the highest quality product for you and your patient.

PO#: Shipping Check Priority: 2nd Day ($8 Flat Rate)Next Day Air

Company:

Address:

City/State/Zip:

Contact:

Phone: Email:

Bill To:Company:

Address:

City/State/Zip:

Contact:

Phone: Email:

Ship To:Date Needed in O�ce:Össur Account #:

IF YOU DON’T HAVE AN ÖSSUR ACCOUNT #, PLEASE FILL OUT FIELDS BELOW

MPT to Floor

KC to Floor

IT to Floor

BK

12

10

8

6

4

2

MPT 0

2

4

6

8

10

12

AK

0

2

4

6

8

10

Length of Limb:

* Please cast or scan as high as you would like the liner to be in length.** Length and circumferences required. If not provided and liner �t requires remake, customer is responsible for cost of remake.

MEASUREMENTS

Negative Cast

Positive Cast

AOP File

LINERSADD WAVE

Recommended for T T l iners

EVO110

EVO310

EVO210

EVO410

Item # Description

EVO110-W

EVO310-W

EVO210-W

EVO410-W

Item #

NOTES

LINER DESIGN

mm

LINER OPTIONSLINER PROFILE

13 mm: Cushion 21 mm: Locking 6 mm: KD, SYMES

6 mm

3 mm

Distal Thickness

Base

Proximal

Standard Design

Add Distal Thickness

Natural / No silking agent

(liner is tacky inside and outside)MatrixProximal Lateral Attachments

Fill InvaginationStovepipe

BILLING & SHIPPING INFORMATION

EVOLUTION TRULY CUSTOM LINER ORDER FORM

© 2019 ÖSSUR, INC. E-072315, 1.00

SEND ALL CASTS, SOCKETS, AND FILES TO: 7199 S CONWAY RD #100 | ORLANDO, FL 32812TEL (888) 839-6213, FAX (800) 788-9878 | CS@OSSUR.COM

PATIENT INFORMATION

CONSTRUCTION *ITEMS IN BOLD ARE THE DEFAULT SELECTIONS UNLESS OTHERWISE SPECIFIED

New Evolution Silk Custom Cushion Liner

Additional Evolution Silk Custom Cushion Liner

New Evolution Silk Custom Locking Liner

Additional Evolution Silk Custom Locking Liner

Molds reta ined for t wo years af ter last l iner order. Two years af ter last l iner order mold wi l l be destroyed.