Alpha DESIGN AK Liner Form > WillowWood > Free the body. Free the spirit.

Today's Date:*

WillowWood Account Number:*

P.O. Number:*

Practitioner Name:*

First Last

Phone:*

Mobile Phone:

E-mail:*

A summary of your completed order form will be emailed to this address upon submission.

Contact me via:*

phone
mobile phone
email

SHIP TO:

Company Name:*

Ship To Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Shipping Options:*

Indicate Shipping Option:*

BILL TO:

Bill To Address:*

Same as Ship To

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

PATIENT INFORMATION:

Patient Identification:*

Write same patient ID on cast as well.
Cast will be disposed of after liner is created unless suggested otherwise in the ''Notes'' section of this form.

Amputation Side:*

Left
Right

If Bilateral, be sure to fill out a form for each cast or shape.

Amputation Level:*

AK
Knee Disarticulation

Limb circumference at highest obtainable level (in inches):*

Level of measurement from distal (in inches):*

no higher than 18''

LINER INFORMATION:

Quantity of this DESIGN Liner:*

WillowWood strongly recommends providing each amputee with two liners.

Liner Type:*

Locking
Cushion
Duo (Fabric-Free)

Cushion only, Dark Gray, Silicone Exterior, Satin Finish, Classic Gel, Includes a Gel Sock

Locking Liner Umbrella Size:*

** Recommended for most liners.

Outer Fabric Type/Color:*

Note: Select fabric is not eligible for pre-stretching.

Pre-stretch liner, if needed?*

Yes
No

Gel Type:*

Classic
Hybrid

Standard Lead Time:*

Alpha DESIGN Liners with Classic Gel have a 5 business day lead time from the date of receipt or verification of this completed form.

Yes, I understand

Standard Lead Time:*

Alpha DESIGN Liners with Hybrid Gel have a 10 business day lead time from the date of receipt or verification of this completed form.

Yes, I understand

Inner-Comfort Cuff:*

This is an add-on feature of $35 extra. Inner fabric follows brim angle. WillowWood recommends inner fabric extend 2'' below socket brim. (NOT available for Select fabric)

Yes
No

Provide fabric height for Medial:*

Provide fabric height for Lateral*

Standard AK Casting Marks

The following marks must be indicated on the cast:

Lateral Distal Femur
Ischium
Scar/Invagination

Knee Disarticulation Casting Marks

The following marks must be indicated on the cast:

Lateral Distal Femur Condyle
Medial Distal Femur Condyle
Scar/Invagination
Ischium
Distal Femur

Click HERE for Casting Mark Examples

Attach P.O.(s): (Cannot exceed 40 MB)

Drop files here or

Accepted file types: jpg, pdf, doc, docx, gif, png, xls, dotx, xlsx, Max. file size: 256 MB, Max. files: 10.

Attach Shape File(s): (Cannot exceed 40 MB)

Shape files may also be sent to aopfiles@owwco.com

Drop files here or

Accepted file types: stl, aop, ak, bk, be, obj, ae, ue, stl, aop, Max. file size: 256 MB.

Notes:

Would you like a DESIGN Technician to contact you before starting this order?*

Yes
No

There is a $75 fee for cancelling an Alpha DESIGN® Liner that is already in progress.*

Yes, I understand.

Alpha DESIGN AK Liner Form

Alpha DESIGN AK Liner Order Form

SHIP TO:

BILL TO:

PATIENT INFORMATION:

LINER INFORMATION:

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