Scottish Rite Custom Order Form 2710 Amnicola Highway Chattanooga, TN 37406 423.624.0946 Fax 423.698.6076 centralfab@fillauer.com Company Account No.
Scottish Rite Custom Order Form Company Account No. Address Line 1 Address Line 2 City, State, Zip Practitioner Phone Email Patient ID Purchase Order Patient Information Age Sex Weight Height A. Diameter and Circumference taken just below Crests B. Right and Left Circumference taken 2 in. below Perineum C. Right and Left Circumference taken 2 in. above Patella D. Diameter at Trochanters E. Distance from Center Hip Joint (CHJ) to Center Knee Joint (CKJ) F. Distance 2 in. below Perineum (Prox. Circ. B) to 2 in. above Patella (Distal Circ. C) G. Distance from Perineum to Top of Condyle H. Abduction Angle ASIS A Trochanter D B C E F 2710 Amnicola Highway Chattanooga, TN 37406 423.624.0946 Fax 423.698.6076 centralfab@fillauer.com Type oo Scottish Rite Orthosis with Thrust Bearing Hip Joints, No Telescoping Bar oo Scottish Rite Orthosis with Thrust Bearing Hip Joints with Telescoping Bar oo Scottish Rite Orthosis with Telescoping Bar oo Scottish Rite Orthosis for Failed Total Hip Prosthesis or for PostSurgical Use Degree of Abduction Right Side oo 0º Abduction oo 10º Abduction oo 25º Abduction oo 35º Abduction oo Variable Abduction Hip Joint Left Side oo 0º Abduction oo 10º Abduction oo 25º Abduction oo 35º Abduction oo Variable Abduction Hip Joint G Total Abduction Angle Motion Control Plate oo Right, set at 0º Extension _________________º Flexion oo Left, set at 0º Extension _________________º Flexion H Notes WF110/12-06/02-22-18Adobe InDesign CC 13.0 (Macintosh) Adobe PDF Library 15.0