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Ship To:
Fax No.
a. Amputation Side: Left Right
b. Amputation Level: AK Knee Disarticulation
c. Custom liners available within the following measurement ranges:
Limb circumference at highest obtainable level (no higher than 12"):
d. Patient ID
Please make sure to write the patient ID on the cast.
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):
Original Spirit MAX Select* e. Outer Fabric Color:
Buff (Original, Spirit, Max fabrics) Gray - Select* Fabric 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.
Yes No
If yes, please provide fabric heights for:
Medial: Lateral:
h. Pre-Stretch Liner, if needed: Yes No
The following marks must be indicated on the cast:
Knee Disarticulation
•Missing marks may result in incorrect gel thicknesses and/or delay the order.