Alpha DESIGN® AK Liner Order Form
Phone: 1-800-848-4930
Please complete this form and then press the "Print" button at the bottom. Please include one copy per cast. Missing information may delay your order. Please fill out form completely. Credit will not be issued due to order forms completed with inaccurate information or incomplete forms. Do NOT cast over a liner. For bilateral amputees, please complete separate forms for each residual limb.

 

To download a .pdf version of this form, click here.

Please have a DESIGN Technician contact me before making this liner. Yes No
I'd like to view and assist in the design of this custom liner with an online webinar session. Yes No

1. Ship To/Bill To Information:

Account No.
P.O. No.

 

Ship To:

Company Name
Address
City/State/Zip
Phone No.
Mobile No.
Fax No.
E-mail Address
Prosthetist
Bill To: Same as Ship To       Different than Ship To
Company Name
Address
City/State/Zip
Phone No.

Fax No.

 

Shipping Options: (Lead Times: Alpha DESIGN Liners with Classic gel have a 5-day lead time and liners with Hybrid gel have a 10-day lead time from the date of verification of this completed form.)

NOTE: UPS Ground is the default shipping option if no option chosen by customer.
UPS Red UPS Blue UPS Ground
Other

2. Patient Information

a. Amputation Side: Left Right

b. Amputation Level:

c. Custom liners available within the following measurement ranges:

  • Proximal: 9" minimum/ 35" maximum
  • Distal: 7" minimum/ 23.5 maximum
  • Limb circumference at highest obtainable level (no higher than 12"):

    Level of measurement from distal (inches):   
    Circumference measurement (inches) 

    d. Patient ID

    Please make sure to write the patient ID on the cast.

     

    3. Liner Information:

    a. Quantity of DESIGN Liners: 1 2
    *WillowWood strongly recommends providing each amputee with two liners.

    b. Liner Type: Cushion Locking

    c. Liner Umbrella Size:
       Standard (medium through extra large plus sizes; recommended for most liners)
       Small (small through medium plus wide sizes)

    d. Outer Fabric Cover: (select one only):

    Select*

    e. Outer Fabric Color:



        Taupe - Select* Fabric

    f. Gel Type:     Classic Hybrid


    g. Inner Comfort Cuff: Add-on feature, $35 extra.

    Inner fabric follows brim angle. WillowWood recommends inner fabric extend 2" below socket brim.
    NOTE: Inner Comfort Cuff not available for use with Select fabric.

       

    If yes, please provide fabric heights for:

    h. Pre-Stretch Liner, if needed:

        Select fabric is not eligible for pre-stretching.

    4. Casting Marks:

    The following marks must be indicated on the cast:

    Knee Disarticulation

  • Lateral Distal Femur Condyle
  • Medial Distal Femur Condyle
  • Scar/Invagination
  • Ischium
  • Distal Femur
  • •Missing marks may result in incorrect gel thicknesses and/or delay the order.

    •Please click here for examples of how to mark the cast for desired gel thickness and other information.

    5. Notes:

    Please note: There is a $75 fee for canceling an Alpha DESIGN Liner that is already in process.

    Alpha DESIGN Liners have a 30-day trial period and a 12-month warranty from date of invoice.

    The Ohio Willow Wood Company
    15441 Scioto Darby Road
    Mt. Sterling, OH 43143
    P: 800.848.4930
    F: 888.878.4858
    Alpha is a registered trademark of The Ohio Willow Wood Company.All specifcations and pricing are subject to change without notice. © 2005 The Ohio Willow Wood Company
    PN-1850-Y April 23, 2019