Brace Order Information - 1 brace per order form Shipping & Billing Information Account # ____________________________P.O. # __________________________ Contact Name________________________________________________________ Phone ________________________________Email __________________________ Shipping Address Name _________________________________________________________________ Address _______________________________________________________________ _______________________________________________________________________ City ________________________ State_________________ Zip _________________ Country _______________________________________________________________ MAGNESIUM COLORS 3001 – Jet Black 3033 – Black Metallic 3038 – Silver Metallic 3013 – Traffic Blue 3067 – Pastel Blue 3071 – Wine Red 3051 – Steel Blue 3023 – Water Blue 3011 – Ultramarine Blue 3017 – Moss Green 3043 – Grass Green 3016 – Yellow Green 3046 – Signal Yellow 3062 – Sahara Gold 3018 – Pure Orange 3022 – Traffic Red 3024 – Traffic White 3019 – Telemagenta See color chart for color options. For a two color brace, list the color number for the top part of the brace first, and the color number for the bottom part second. Shell Color Number(s) ___________________________________________________ ALUMINUM COLORS 2001 – Jet Black 2033 – Black Metallic 2038 – Silver Metallic 2029 – Traffic Gray Metallic 2013 – Traffic Blue 2067 – Pastel Blue 2069 – Cobalt Blue 2051 – Steel Blue 2023 – Water Blue 2040 – Sky Blue 2032 – Stardust Blue Metallic 2017 – Moss Green 2036 – Moss Green Metallic 2043 – Grass Green 2046 – Signal Yellow 2062 – Sahara Gold 2018 – Pure Orange 2022 – Traffic Red 2031 – Traffic Red Metallic 2021 – Brown Red 2071 – Wine Red 2024 – Traffic White 2019 – Telemagenta Manufacturing Turnaround Custom braces are guaranteed to ship within 24 hours when the order is received by 2:00pm CST. Billing Information Business Name_________________________________________________________ Address _______________________________________________________________ _______________________________________________________________________ City ________________________ State_________________ Zip _________________ Country ____________________ Phone____________________________________ Account # ____________________________________________________________ Shipping Method Shipped using FedEx or UPS Ground unless alternate method is selected below (additional charges apply to following shipping methods): q FedEx Priority Overnight ® q UPS Next Day Air ® q UPS 2 Day ® q FedEx Standard Overnight ® q UPS Next Day Air Saver ® q UPS 2 nd Day Air ® q Axiom q Magnesium q Aluminum q Axiom OA q Magnesium q Aluminum Degrees of offset (up to 8°) _________ q Axiom Adjustable OA q Magnesium q Aluminum q Axiom-D q Magnesium q Aluminum q Axiom-D OA q Magnesium q Aluminum Degrees of offset (up to 8°) _________ q Axiom-D Adjustable OA q Magnesium q Aluminum q DUO (Aluminum only) q SHORT 13” q STND 15” q Legacy (Aluminum only) q SHORT 14” q STND 16” q Thruster RLF (Aluminum only) q SHORT 16” q STND 17” q Z-12 (Magnesium only) q STND 13” q EXT 15” q Z-12 OA (Magnesium only) q STND 13” q EXT 15” Degrees of offset (up to 8°) _________ q Z-12 Adjustable OA (Magnesium only) q STND 13” q EXT 15” q Z-12-D (Magnesium only) q STND 13” q EXT 15” q Z-13 (Aluminum only) q STND 13” q EXT 15” q 20.50 q Magnesium q Aluminum q STND 11” q EXT 13” q 20.50 OA q Magnesium q Aluminum Degrees of offset (up to 4°) _________ Brace Options & Accessories (additional charges may apply) q “D-Ring” Strap Style q PCL Strap q Patella Guard q Undersleeve: QTY ________ q Oversleeve: QTY ________ q Patella/Femoral Guard q Flexion/Extension Stop Kit q AFO Attachment (Thruster RLF only) Brace Color Options Pads on Brace q Everyday (All) q High-Activity (Axiom, Z-12, and DUO braces only) q Ultrasuede (Axiom only) Additional Pads: Quantity _______ CAST MOLD INSTRUCTIONS: Knee Flexion: From 10 degrees flexion • Materials: Plaster or fiberglass (preferred) with little or no padding • Cast Length: 9 to 10 inches above and below knee joint • Markings: Use a marker to indicate the patella, fibular head, and tibial crest on the inside and outside of the cast mold • Cut Location: A single cut POSTERIOR of knee in the sagittal plane • Shipping: Write “Attention: Custom Department” clearly on box and mail to the following address with this form inside the cast mold: 2601 Pinewood Dr, Grand Prairie, TX 75051 Bledsoe FitKit Measuring System Data (see How To Measure instructions on the back of this order form) _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ 7” above KC: _________________ 3” above KC: _________________ 3” below KC: _________________ 6” below KC: _________________ Knee Width Measurement Bledsoe Hand Tool _______________________________ Other (specify)_______________________________ Measurements taken by: ____________________ Tibial Tool Tracing Board Circumference Measurements A1 A2 1 4 B1 B2 2 5 C1 C2 3 6 D1 D2 E1 E2 F1 F2 G1 G2 Custom Knee Brace Order Form To order, call Customer Care: 1.888.253.3763 or fax your order to: 972.660.5495 (from Canada, fax toll-free to: 855.397.4159) Patient Information Patient Name ________________________________________________________ Age ______________ Height (inches) ____________ Weight (lbs.)______________ Sex q M q F Diagnosis _____________________________________________ Phone: ____________________________________________ Affected Leg q Left q Right Instability/Deficiency: q ACL q PCL q CI q MCL/LCL/Meniscus q Patellofemoral Pain q None (Prophylactic Use) OA (Osteoarthritis): q Medial Compartment (Varus Condition) q Lateral Compartment (Valgus Condition)