Wood Cheneau Rigo 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 (*)

    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 (*)



    Practitioner Rigo Classification

    Grant / Raul / Rigo Classification

    X-Ray Analysis


    Cobb Angleº / Side (Select Left or Right)

    Scoliometer Rotationº / Side (Select Left or Right)

    Proximal

    Apex

    Proximal

    Clinical Evaluation

    AP Measurement

    Axilla Left :

    Right :

    ASIS Left :

    Right :

    Additional Patient Information

    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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