(AT) Align Technologies Brace

Measurement Order Form

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(*) Required Fields

Please fill out the following information to proceed with the brace production.

    Eval Date (*)

    Practitioner (*)

    Practitioner e-mail (*)

    Ship to address (*) (Please stamp or write full address below.)

    Due Date

    PO#

    Patient Name (*)

    DOB (*)

    Age (*)

    Sex (*)

    Age/Date Menarche

    Premenarchal

    Height (*)

    Weight (*)

    Brace Color ( View Color Catalog )

    Color pattern

    No Color ?

    * Scan preferred for ALL cases. When scan is poor, proceed to casting. The cast must include the shoulder girdle and be draped, marked with landmarks and scanned. Please send scan of cast.

    Previous Treatment : (including non WCR)

    Select one (*)


    Please specify. (*)

    Brace Classification (Align Clinic Use Only)

    X-Ray Analysis

    Date of X-Ray (*)

    IB or OOB (*)

    Risser Sign (*)

    0,1,2,3,4,5 or unsure

    Triradiate Cartilage (*)

    Decompensation (Location of C7 with respect to central sacral line) (*)

    X-Ray files (*)

    Cobb Angleº / Side (Select Left or Right)

    Scoliometer Rotationº / Side (Select Left or Right)

    Proximal

    Apex

    Proximal

    Thoracic

    Apex

    Thoracic

    Thoracolumbar

    Apex

    Thoracolumbar

    Lumbar

    Apex

    Lumbar

    Include all patient information and fabrication notes here (max. 540 cc)

    CAD/MOD Notes (Align Clinic Use Only)

    Translation

    Ventral

    Elongation

    Balance

    Clinical Evaluation

    Trunk is decompensated to the (*)

    Patient standing - Pelvic translation to the (*)

    Forward bending - Pelvic translation to the (*)

     

    AP Measurement

    Axilla Left :

    Right :

     

    ASIS Left :

    Right :

     

    Additional Patient Information

    Flexibility

     

    Complete Order Checklist

    1. Current Out of Brace X ray date most recent x-ray taken
    (must be within 6 mo) / (include all previous x-rays)

    2. Clinical Photos (.jpg format) OOB and in current older brace

    3. Captevia Scan (CPV or STL format only)

    4. Brace Color

    5. Select one

     

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