BK

Alpha DESIGN® BK Liners Order Form Please complete this form and include one copy per cast. Fill out this form completely as missing information may delay your order. Credit will not be given for inaccurate information provided or for incomplete order forms.

Do NOT cast over a liner – see page 2 for important guidelines.

5. Notes: _________________________________________

_______________________________________________

2. Patient Information: a. Amputation Side: Left Right b. 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 16"): Level of measurement from distal (inches): _____ Circumference measurement (inches): _________c.PatientID_________________________________ Write the patient ID on cast.

3. Liner Information:a.QuantityofDESIGNLiners: 1 2 *WillowWood strongly recommends providing each amputee with two liners.

b. Liner Type: Cushion Locking

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

d. Outer Fabric Cover: Original Spirit MAX Select*

e. Outer Fabric Color (choose one only): Buff - Original, Spirit, MAX fabrics Brown - Original & Spirit fabrics only Green/Gray-Original&Spiritfabricsonly Gray-Selectfabriconly Taupe - Select fabric only

f.GelType: Classic Hybrid

g.Pre-StretchLiner,ifneeded: Yes No *Select fabric is not eligible for pre-stretching.

Alpha is a registered trademark of The Ohio Willow Wood Company. All specifications and pricing are subject to change without notice.

©2005TheOhioWillowWoodCompany PN-1773-X21APRIL2015

The Ohio Willow Wood Company 15441SciotoDarbyRoadMt.Sterling,OH43143P: 800.848.4930F:888.878.4858

4. Casting Marks:The following marks must be indicated on the cast: •FibulaHead •DistalFibula •DistalTibia •Patella •MPT •Missingmarksmayresultinincorrectgelthicknesses and/ordelaytheorder. •Pleaseseepage2forexamplesofhowtomarkthe cast for desired gel thickness and other information.

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

Please note:Thereisa$75feeforcancelinganAlphaDESIGNLinerthatisalreadyinprocess. AlphaDESIGNLinershavea30-daytrialperiodfromdateofinvoiceanda12-monthwarrantyfromdateofinvoice.

Bill To: (if different than shipping address)____________________________________________ Company Name

____________________________________________ Address _____________________________________________ City/State/Zip

____________________________________________ PhoneNo. Mobile No.

____________________________________________ FaxNo.

Shipping Options

(Leadtimes:AlphaDESIGNLinerswithClassicgelhavea5-dayleadtimeandlinerswithHybrid gel have a 10-day lead time from the date of verification of this completed form.)NOTE:UPSGroundisthedefaultshippingoptionifnooptionchosenbycustomer. UPSRed UPSBlue UPSGround

Other __________________________________

1. Ship To/Bill To Information:________________ ____________ ________ AccountNo. P.O.No. Date

Ship To:

____________________________________________ Company Name ____________________________________________ Address ____________________________________________ City/State/Zip

____________________________________________ PhoneNo. FaxNo.

_______________________________________________________________ E-mail Address

____________________________________________ ProsthetistName

This form will allow you to order an Alpha DESIGN® Liner with custom modifications for either a "Standard" shaped BK limb or for a "Symes" shaped BK limb. Below are diagrams that explain what the custom profile of each type will be. For greater control over thedesign ask WillowWood about the OMEGA® Scanner 3D and the Alpha DESIGN Liner wizard.

Please wrap plaster 5" (12 cm)above MPT

Fibula Head

Distal Fibula

Distal Tibia

MPT Bar

Patella

See the diagram below for the marks that must be indicated on the cast. Missing marks may result in no additional gel at the location and may delay the order.

For a standard Alpha DESIGN BK Liner from a cast the profile will be:*6 mm base thickness*9 mm distal thickness over the distal fibula and tibia*3 mm proximally above the socket *3 mm posteriorly behind the patella*9 mm over the fibula head

For a Symes Alpha DESIGN BK Liner from a cast the profile will be:*3 mm base thickness*3 mm of proximally above the socket *3 mm posteriorly behind the patella*Up to 25 mm to fill the necking area above the malleolus. This area will be filled to create a more cylindrical shaped limb.*6 mm over fibula head

This is defined as the distal end.

Please wrap plaster 5" (12 cm)above MPT

Patella

Additional thickness to 25 mm

3 mm Base

3 mm

9 mm

6 mm

9 mm (Fib Head)

3 mm

This is defined as the distal end.

9 mm (Fib Head)

Proximal View

Maximum of 25 mm thickness.

Alpha DESIGN® BK Liners Order Form Important Casting & Marking Guidelines

Please Note: •Forbilateralamputees,pleaseuseseparateformsforeachresiduallimbforbestsocket/lineraccuracy. •Whencasting,pleasecastpatientatleast4”to5”abovetheknee. •PleasemakesuretoincludethepatientIDonthecast.

Proximal View

MPT

Distal Tibia

Patella

Fibula Head

Distal Fibula

Seetheexamplesfor the marks that must be indicated

on the cast. Missing marks

may result in no additional gel at the

location and may delay the order.

Patella

MPT

Fibula Head Distal TibiaLateral Malleolus