Alpha DESIGN BK Liner Form < WillowWood < Free the body. Free the spirit.

Alpha DESIGN® BK Liner Order Form

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
e-mail

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 ID:*

Write patient ID on cast as well. Cast will be disposed of after liner is created unless suggested other wise 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.

Limb circumference at highest obtainable level (in inches)*

Level of measurement from distal (in inches):*

Less than 34''.

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:*

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

Casting Marks:

The following marks must be indicated on the cast. DO NOT CAST OVER LINERS.

Fibula Head
Distal Fibula
Distal Tibia
Patella
MPT

Click HERE for Casting Mark Examples

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

Drop files here or

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

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

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

Drop files here or

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

Notes:

Would you like a DESIGN Technician to contact you before creating this liner?*

Yes
No

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

Yes, I understand.

Alpha DESIGN BK Liner Form

Alpha DESIGN® BK Liner Order Form

SHIP TO:

BILL TO:

PATIENT INFORMATION:

LINER INFORMATION:

Find Your Liner Part Number