Office:
160 Witter Rd.
Altamont, NY 12009
Email:
mvprosthetics@yahoo.com

Phone:
518-872-0374

Fax:
518-872-7107

AK CAD Order Form

Contact Info

Company Name
Company Address
Phone #
Clinician
Shipping Address
Date Due

Patient Info

Patient Name or P.O.
Height
Weight
Age
Occupation
Gender
Ethnicity
Side
Type
Functional Level

Prosthetic Info



|
type

|
type

|
type
Brim Style
view template (PDF)
view template (PDF)
view template (PDF)
view template (PDF)
view template (PDF)
view template (PDF)
view template (PDF)
view template (PDF)
view template (PDF)
Reduce/Increase

Addition
cm to length
Make to Measurement
Alignment
Flexion
Abduction
Adduction

Anatomy Details

A: 0" or 0cm
B: 2" or 5cm
C: 4" or 10cm
D: 6" or 15cm
E: 8" or 20cm
F: 10" or 25cm
G: 12" or 30cm
H: I.T. to the distal end of residual limb

Special Instructions & Submit

Additional Info

After submitting this form, we will review the information and be in touch with you to discuss next steps.