Silicone Prosthetic Cover Measurement Form

Order Number *

Facility Name *

Facility Address *

Practitioner Name *

Practitioner Email *

Practitioner Phone *

Sound Side Measurements

1. Height to Apex of Calf (inches) *

2. A/P Width at Apex of Calf (inches) *

3. M/L Width at Apex of Calf (inches) *

4. Height to Smallest Dimension Proximal to Ankle (inches) *

5. A/P Width at Smallest Dimension Proximal to Ankle (inches) *

6. M/L Width at Smallest Dimension Proximal to Ankle (inches) *

7. Sound Side Foot Length (centimeters) *

Upload pictures of the patient standing, from the waist down, with the prosthesis on, without shoes.

Take 4 photos from the following angles:

- Front

- Back

- Left

- Right

Follow Steps Above *

Thank you for your submission. Our team will review it and respond as soon as possible.

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