AK BY MEASUREMENT
WillowWood’s Custom Fabrication Department Order Form
To download a .pdf version of this form, click here.
Date
Prosthetist
Facility
Purchase Order #
Email Address
Account #
Shipping To
Shipping Address
City
State
Zip Code
Phone
Fax
SHIPPING INFORMATION
Date Needed
UPS Red
UPS Ground
UPS Blue
Other
Special Instructions
PATIENT INFORMATION
Patient ID
Male
Female
Height
Weight
Amputation Side
Right
Left
Amputation Level
AK
Knee Disarticulation
Amount of Reduction
Measurements taken over liner?
Yes
No
What type and style of liner?
BASIC SOCKET INFORMATION
Distal attachment (choose one). Locks are not included in the check socket price. Additional charges for locks will apply.
Alpha Lock
Alpha Lamination Lock
Alpha Locking Lanyard
Alpha Lanyard Distal Adapter Only
Alpha Lock Distal Adapter Only
G-Lock
Other distal adapter
Green Dot Valve (for pulling into socket)
Suction Pro
Socket Attachment Block with European 4-Hole Pattern
Provision for Bull Dog Locks
LimbLogic VS
No distal attachment
Check Socket Material?
Vivak
Northplex
Orfit Stiff
Additional WillowWood components ordered
MEASUREMENTS
Degree of Contracture
Hip Flexion
o
 
Stump Adduction
o
 
Abduction
o
Brim Shape
Special Instructions
Distance
Below
Ischium
(inches)
Circumference
Measurement
0
2
4
6
8
10
ischium
Femur Length
Residual Limb Length
 
WillowWood
15441 Scioto Darby Road
Mt. Sterling, OH 43143
P: 800-848-4930
F: 888-878-4858