wcr brace new logo 395x150-02

WCR Brace

REDO

Order Form

AC New Logo 395x150-03

(*) Required Fields

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

    Today's Date.(*)

    1st Fitting Date (*)

    Practitioner (*)

    Practitioner e-mail (*)

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

    Patient Name (*)

    DOB (*)

    Age (*)

    Sex (*)

    Age/Date of menarche

    Premenarchal

    Height (*)

    Weight (*)

    Brace Color ( View Color Catalog )

    Color pattern

    No Color ?

    Due Date

    Select one (*)


    Please specify.

    Grant / Raul / Rigo Classification

    Instructions for REDO

    1. Do a test ‐ socket type fitting of brace and provide clinical photos in brace with black Sharpie pen marks.

    2. Provide written description of #1 above in addition to CP in‐brace.

    Include all patient information and fabrication notes here

     

    REDO Checklist

    1. CP in-brace photos

    2. Sharpie marks indicating where to add/subtract pressures

    3. Give measurement amount in mm. to add/substract (i.e. -12mm., +10mm.)

    4. Date of initial fitting

    5. Use

    6. Date of Xray to be used

    All items must be included for order to be accepted

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