THIS PRINT METHOD IS PROHIBITED. THE FORM WILL NOT BE ACCEPTED.

Alpha^® DESIGN^™ AK Liners and Test Socket Order Form

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.

1. Ship To/Bill To Information:
Account No.
P.O. No.
Ship To:

Company Name
Address
City/State/Zip
Phone 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 (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

YES, I'd like to complete this Alpha DESIGN
Liner by webinar

2. Patient Information:
     a. Amputation Side:        Left    Right
     b. Amputation Level:        AK     Knee Disarticulation
     c. Limb Length (I.T. to distal end of limb):
     d. Circumference of limb at 12” proximal to
        distal end (or highest point obtainable):
     e. Height:     Weight:     Age:
     f. 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. 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
     Alpha Lanyard
     Alpha Lamination Lock (must use Northplex)
     Alpha Lock Distal Adapter Only
     Alpha Lanyard Distal Adapter Only
     Socket Attachment Block - 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.

Degree of Contracture: Hip Flexion:
Limb Abduction: Adduction:
Brim Shape (required, see back for options):

Dist. below Ischium	Limb Measurement
2"
4"
6"
8"
10"
12"
14"
16"

A standard reduction of 17 ply is made
when socket is created. This is approximately
equivalent to a reduction of 1.5" or
4 cm circumferentially.

Femur Length
Limb Length

4. Liner Information:
     a. Quantity of DESIGN Liners:   1     2
     b. Liner Type:    Cushion    Locking
     c. Outer Fabric Cover(select one only; Buff color only):
          Original
          Spirit                    Spirit with stability strip

Please note all liners will have outer fabric color of Buff.

     d. Inner Comfort Cuff: This is an add-on feature and costs
        $25 extra. Inner fabric will follow brim angle. Ohio Willow Wood
        recommends that inner fabric extend 2" below socket brim.
            Yes      No

If yes, please provide fabric heights for:
         Medial:      Lateral:

     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. Casting Marks:
The following marks must be indicated on the cast:
    Knee Disarticulation:
              • Lateral Distal Femur Condyle • Ischium
              • Medial Distal Femur Condyle   • Distal Femur
              • Scar/Invagination
    Standard AK:
              • Lateral Distal Femur                • Ischium

• Missing marks may result in incorrect gel thicknesses and/or delay the order.

• Please see back page for examples of how to mark the cast desired gel thickness and other information.

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