Transtibial Prosthesis

Account Information

Ship To Information

NOTE: To follow regulatory guidelines, Ottobock will assemble the prostheses per your direction except for attaching the foot, which will be packaged separately with your order.

Please mail your completed Ottobock order form and a negative impression of the patient's limb to the address below. An Ottobock Fabrication Coordinator will contact you.

Shipping Options:

UPS Next Day UPS Ground UPS 2-Day Other:

Once this form is complete, please send to Ottobock via fax or email.

Order Quote Only Click to Email Form

For clinical questions, call 800 328 4058.

Notes:

Patient Information

Socket Information Provided With

• Positive Cast
• ETS Form
• Existing Socket
• Test Socket

Socket Fabrication Instructions

• Rough Trial
• Laminated Socket
• Heavy-Duty Lamination
• Soft Insert Liner
• Distal End Pad
• Thermoplastic Liner
• Thermolyn Supra Flexible
• Proflex With Silicone
• Proflex Without Silicone

Components

Pylon

30mm 34mm Steel Titanium Aluminum

Pylon Adapter

4R39 Torque Absorber

Ottobock Part Number – specify manufacturer if not Ottobock part:

Foot

Ottobock Other

Foot Part Number: Specify manufacturer, if not Ottobock Part Number:

Shuttle lock

Ottobock Other

Part Number: Specify manufacturer, if not Ottobock Part Number:

Provided By Customer: Yes No

Measurements

(Take all measurements with patient's shoe off. Record all measurements in millimeters unless otherwise noted.)

1. Residual Limb Flexion angle: of Flexion

2. Set Socket in:

3. Foot size: cm

4. Heel height: mm

Medial Tibial Plateau (MTP)-to-Floor Measurement

This diagram illustrates measurements taken from the Medial Tibial Plateau (MTP) to the floor. It shows points for Calf Measurements and Ankle Measurements.

The diagram depicts a human leg from the knee down. It is annotated to guide the user in taking specific measurements. The primary measurement indicated is from the Medial Tibial Plateau (MTP) down to the floor. Two circular icons with directional arrows are placed on the leg, labeled 'Calf Measurements' and 'Ankle Measurements', indicating where circumference or other measurements should be taken.