Request CAD-CAM Order

Practitioner's First Name

Practitioner's Last Name

Email Address

Contact Phone Number

Clinic Name

Ship to Address

Patient Name

City, State & Zip

Order PO#

Date Requested By

Preferred Shipping Method

Shipping Method RequestedUPS Ground 3-5 daysUPS 2nd DayUPS Next Day Air Saver by end of dayUPS Next Day Air by 3 pmUPS Next Day Air Early AM by 9 amFEDEX GroundCustomer's UPS AccountCustomer's Fedex Account

Please enter your shipper number if requested method.

Side Requested
RightLeft

Socket Type Requested
AKBK

Measurements Taken Over Liner?
YesNo

Service Requested-Required

CAD-CAM TYPECAD-CAM Carving OnlyCAD-CAM Carving and test socketCAD-CAM Digitizing

If "Yes" please indicate amount to be reduced by below.

Material Requested for Test Socket

Test Socket Material TypePETGThermolynPolypro

Ischium or Perineum to Distal End

Distal End Attachment Type

NoneGrace PlatePyramidWood BlockOther

Please enter type if "Other" is selected

Residual Limb Measurement

Brim Style

Brim Style TypeNMLSNMLAggressiveQuad- StandardOther please list

If "Other" please list style requested

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