Thank you for your interest in Alpha DESIGN® Liners. Complete this form electronically to receive a savings.
Alpha DESIGN® BK Liners and Test Socket Order Form             
Phone: 800-848-4930
Please complete this form and then press the "Print" button at the bottom. Include one copy with cast of residual limb only. Do NOT cast over a liner. For bilateral amputees, please complete separate forms for each residual limb. Missing information may delay your order.

To download a .pdf version of this form, click here.
   
1. Ship To/Bill To Information:
Account No.
 
Ship To:
 
Name
Address
City/State/Zip
Phone No.
Fax No.
Prosthetist
 
P.O. No.
Date
 
Bill To: Same as Ship To       Different than Ship To
Complete if Billing information differs from Shipping information
Name
Address
City/State/Zip
Phone No.
Fax No.
 
Shipping Options (Cushion liners will ship within 3 days, and locking liners within 4 days of verification of this completed form)
 
UPS Red UPS Blue UPS Ground
Other
   
2. Patient Information:
     a. Amputation Side:                  Left          Right
     b. Limb Length (MPT to Distal):
     c. Circumference of limb at 16” above distal end (or highest          point obtainable):
     d. Patient ID: 
     Please make sure to write the patient ID on the cast.

3. Socket Information:
     a. Do you want a Check Socket (TSB) provided?
            Yes        No
     If YES,
         b. Check Socket Material:      Vivak       Northplex
         c. Check Socket Thickness:   Single Pull       Double Pull
         d. Distal Attachment: (select one only) Locks are not included in the
                 check socket price. Additional charges for locks will apply.
  G-Lock      Suction Pro
  Alpha Lock  Green Dot Valve (for pulling into socket)
  Alpha Locking Lanyard     Alpha Lamination Lock (must use Northplex)
   Alpha Lock Distal Adapter Only
   Alpha Lanyard Distal Adapter Only
   Socket Attachment Block with European 4-Hole Pattern
   Other Distal Adapter
          e. Additional OWW Components: 
      
     
Sockets will be constructed using Ohio Willow Wood components.
Should you want parts from competitors used in the socket, please provide with cast when placing order.
  		4. Liner Information:
     a. Quantity of DESIGN Liners:  1         2        More  
     b. Liner Type:       Cushion        Locking
     c. Outer Fabric Color:
            Green/Gray    Brown    Buff
     d. Outer Fabric Cover:
            Original    Spirit    MAX
     e. Liner Umbrella Size (for Medium and Medium Plus sizes ONLY. All
        other liners are made with the corresponding sized umbrella.):
           Standard (recommended for most liners)
           Small
     f. Pre-Stretch liner: Yes     No

 5. DESIGN Liner Type:
               Standard               Symes

6. Casting Marks:
The following marks must be indicated on the cast:
              • Fibula Head       • Distal Fibula       • Distal Tibia
              • Patella              • MPT
    • Missing marks may result in incorrect gel thicknesses and/or delay the order.
Notes:


Shape files re-ordered within 9 months of original are duplicate liners.
Alpha is a registered trademark of Ohio Willow Wood.
All specifcations and pricing are subject to change without notice.
© 2005 Ohio Willow Wood
15441 Scioto Darby Road
Mt. Sterling, OH 43143