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PRODUCT ORDER FORM PAGE 1 CUSTOMER # P.O.# DATE PROSTHETIST INFORMATION BILLING SHIPPING (LEAVE BLANK IF SAME AS BILLING) FACILITY/ATTN: FACILITY/ATTN: ADDRESS ADDRESS CITY STATE/ZIP CITY STATE/ZIP PHONE FAX PHONE FAX CARRIER* ¨ UPS ¨ OTHER DATE REQUIRED TIME *ORDERS SHIP UPS GROUND ON THE FOLLOWING DAY UNLESS SPECIFIED. EMAIL PATIENT INFORMATION PROSTHETIST (NAME, TITLE) REQUISITIONER PATIENT (FIRST, LAST) WEIGHT ¨ LBS ¨ KG AMP LEVEL ¨ AK ¨ BK ¨ HIP ¨ KNEE ¨ SYMES ADJUSTABLE HEEL IMPACT LEVEL: ¨ LOW ¨ MODERATE PART ID SIDE AC AC L R Caucasian Brown SHELL COLOR MOUNTING B C BUTTON PLACEMENT L M DP IP BC C DP IP Integrated Pyramid Dynamic Pylon* B SIZE IP DP L M Medial Lateral N W M L 21-28cm *See options K2 IMPACT LEVEL: ¨ LOW PART ID SIDE BE BE L R SHELL COLOR B T C Caucasian Tan Brown K2 MOUNTING SIZE EN EN B T C OPTIONS: ¨ Shelltread *Dynamic Pylon: ¨ Male ¨ Female ¨ 4-hole WIDTH C T B N W Wide 23-26cm only W Narrow N OPTIONS: ¨ Shelltread 21-30cm IMPACT LEVEL: ¨ LOW PART ID SIDE CS CS L R SHELL COLOR B T C SIZE EN EN B T C Caucasian Tan Brown MOUNTING C T B OPTIONS: ¨ Shelltread 21-30cm EMAIL COMPLETED ORDER FORM TO: orders@college-park.com 27955 College Park Dr, Warren, MI 48088, USA TOLL FREE 800.728.7950 FAX 586.294.0067 ON THE WEB www.college-park.com PRODUCT ORDER FORM PAGE 2 CUSTOMER # P.O.# DATE PROSTHETIST INFORMATION BILLING SHIPPING (LEAVE BLANK IF SAME AS BILLING) FACILITY/ATTN: FACILITY/ATTN: ADDRESS ADDRESS CITY STATE/ZIP CITY STATE/ZIP PHONE FAX PHONE FAX CARRIER* ¨ UPS ¨ OTHER DATE REQUIRED TIME *ORDERS SHIP UPS GROUND ON THE FOLLOWING DAY UNLESS SPECIFIED. EMAIL PATIENT INFORMATION PROSTHETIST (NAME, TITLE) REQUISITIONER PATIENT (FIRST, LAST) WEIGHT ¨ LBS ¨ KG AMP LEVEL ¨ AK ¨ BK ¨ HIP ¨ KNEE ¨ SYMES K3 IMPACT LEVEL: ¨ LOW ¨ MODERATE ¨ HIGH PART ID SIDE HZ HZ L R SHELL COLOR B T C B T C C T B OPTIONS: ¨ Shelltread 21-30cm IMPACT LEVEL: ¨ LOW PART ID SIDE OK2 L R OK2 SHELL COLOR B T C MOUNTING SIZE EN EN B T C Caucasian Tan Brown K3 SIZE EN EN Caucasian Tan Brown K2 MOUNTING C T B OPTIONS: ¨ Shelltread 21-30cm IMPACT LEVEL: ¨ LOW ¨ MODERATE PART ID SIDE ODK3 L R ODK3 SHELL COLOR B T C SIZE EN EN B T C Caucasian Tan Brown MOUNTING C T B OPTIONS: ¨ Shelltread 21-30cm EMAIL COMPLETED ORDER FORM TO: orders@college-park.com 27955 College Park Dr, Warren, MI 48088, USA TOLL FREE 800.728.7950 FAX 586.294.0067 ON THE WEB www.college-park.com PRODUCT ORDER FORM PAGE 3 CUSTOMER # P.O.# DATE PROSTHETIST INFORMATION BILLING SHIPPING (LEAVE BLANK IF SAME AS BILLING) FACILITY/ATTN: FACILITY/ATTN: ADDRESS ADDRESS CITY STATE/ZIP CITY STATE/ZIP PHONE FAX PHONE FAX CARRIER* ¨ UPS ¨ OTHER DATE REQUIRED TIME *ORDERS SHIP UPS GROUND ON THE FOLLOWING DAY UNLESS SPECIFIED. EMAIL PATIENT INFORMATION PROSTHETIST (NAME, TITLE) REQUISITIONER PATIENT (FIRST, LAST) WEIGHT ¨ LBS ¨ KG AMP LEVEL ¨ AK ¨ BK ¨ HIP ¨ KNEE ¨ SYMES K3 IMPACT LEVEL: ¨ LOW ¨ MODERATE ¨ HIGH PART ID SIDE OX OX L R SHELL COLOR MOUNTING DP* DP* J B T C J B T C Caucasian Tan Brown Jet Black C T B J 21-30cm IMPACT LEVEL: ¨ LOW FIRMNESS PART ID AK OPTIONS: ¨ Shelltread *Dynamic Pylon: ¨ Male ¨ Female ¨ 4-hole WIDTH N W *See options STUBBIES SK SIZE F SM 0-120 lbs 121-220 lbs 221-275 lbs S M F N W Wide 24-30cm only W Narrow N QUANTITY 12Single Pair 1 2 EMAIL COMPLETED ORDER FORM TO: orders@college-park.com 27955 College Park Dr, Warren, MI 48088, USA TOLL FREE 800.728.7950 FAX 586.294.0067 ON THE WEB www.college-park.com PRODUCT ORDER FORM PAGE 4 CUSTOMER # P.O.# DATE PROSTHETIST INFORMATION BILLING SHIPPING (LEAVE BLANK IF SAME AS BILLING) FACILITY/ATTN: FACILITY/ATTN: ADDRESS ADDRESS CITY STATE/ZIP CITY STATE/ZIP PHONE FAX PHONE FAX CARRIER* ¨ UPS ¨ OTHER DATE REQUIRED TIME *ORDERS SHIP UPS GROUND ON THE FOLLOWING DAY UNLESS SPECIFIED. EMAIL PATIENT INFORMATION PROSTHETIST (NAME, TITLE) REQUISITIONER PATIENT (FIRST, LAST) WEIGHT ¨ LBS ¨ KG AMP LEVEL ¨ AK ¨ BK ¨ HIP ¨ KNEE ¨ SYMES IMPACT LEVEL: ¨ MODERATE ¨ HIGH K3 PART ID SIDE SO SO L R SHELL COLOR HOUSING J B T C SIZE N W T SG M P J B T C Caucasian Tan Brown Jet Black T SG M P C T B J WIDTH Perfect Pink Midnight Black Silver Gold Tactical P M S G T 21-30cm N W Wide 24-30cm only W Narrow N OPTIONS: ¨ Shelltread Adapters: ¨ Rotatable Adapter ¨ Rotatable Receiver ¨ Standard Adapter ¨ Standard Receiver CUSTOM ENGRAVINGS CHECK ONE BOX UNDER DESIGN. PLEASE ALLOW 2 EXTRA DAYS FOR PROCESSING. NO ADDITIONAL CHARGE. SOLEUS ONLY. NO ENGRAVING K2 I AM FEARLESS I AM STRONG I AM DYNAMIC LIGHTNING ON YOUR FEET HEART AND SOLEUS WHOOPS A DAISIES SUPER STARS HOME OF THE BRAVE FLAME ON IMPACT LEVEL: ¨ LOW PART ID SIDE TO TO L R SHELL COLOR B T C SIZE EN EN B T C Caucasian Tan Brown MOUNTING C T B OPTIONS: ¨ Shelltread 21-30cm EMAIL COMPLETED ORDER FORM TO: orders@college-park.com 27955 College Park Dr, Warren, MI 48088, USA TOLL FREE 800.728.7950 FAX 586.294.0067 ON THE WEB www.college-park.com PRODUCT ORDER FORM PAGE 5 CUSTOMER # P.O.# DATE PROSTHETIST INFORMATION BILLING SHIPPING (LEAVE BLANK IF SAME AS BILLING) FACILITY/ATTN: FACILITY/ATTN: ADDRESS ADDRESS CITY STATE/ZIP CITY STATE/ZIP PHONE FAX PHONE FAX CARRIER* ¨ UPS ¨ OTHER DATE REQUIRED TIME *ORDERS SHIP UPS GROUND ON THE FOLLOWING DAY UNLESS SPECIFIED. EMAIL PATIENT INFORMATION PROSTHETIST (NAME, TITLE) REQUISITIONER PATIENT (FIRST, LAST) WEIGHT ¨ LBS ¨ KG AMP LEVEL ¨ AK ¨ BK ¨ HIP ¨ KNEE ¨ SYMES K3 IMPACT LEVEL: ¨ LOW ¨ MODERATE PART ID SIDE TB TB L R SHELL COLOR J B T C C T B J *Jet Black not available with Sandal Toe. TOE SIZE N W S R S R OPTIONS: ¨ Shelltread WIDTH Regular Toe leave blank Sandal Toe S 21-30cm N W Wide 24-30cm only W Narrow N Wide not available with Sandal Toe. IMPACT LEVEL: ¨ HIGH PART ID SIDE TP TP L R SHELL COLOR B T C B T C Caucasian Tan Brown K3 EN EN J B T C Caucasian Tan Brown Jet Black* PEDIATRIC MOUNTING MOUNTING SIZE ALX EN C T B ALX EN Endo Exo EN ALX OPTIONS: ¨ Shelltread ¨ Exo Alignment Tool ¨ Exo Block ¨ Endo Sealing Boot 16-21cm IMPACT LEVEL: ¨ LOW ¨ MODERATE ¨ HIGH PART ID SIDE TS TS L R SHELL COLOR J B T C J B T C Caucasian Tan Brown Jet Black MOUNTING SIZE ALX EN C T B J ALX EN Endo Exo OPTIONS: ¨ Shelltread ¨ Exo Alignment Tool ¨ Exo Block ¨ Endo Sealing Boot WIDTH N W EN ALX 22-31cm N W Wide 24-31cm only W Narrow N EMAIL COMPLETED ORDER FORM TO: orders@college-park.com 27955 College Park Dr, Warren, MI 48088, USA TOLL FREE 800.728.7950 FAX 586.294.0067 ON THE WEB www.college-park.com PRODUCT ORDER FORM PAGE 5 CUSTOMER # P.O.# DATE PROSTHETIST INFORMATION BILLING SHIPPING (LEAVE BLANK IF SAME AS BILLING) FACILITY/ATTN: FACILITY/ATTN: ADDRESS ADDRESS CITY STATE/ZIP CITY STATE/ZIP PHONE FAX PHONE FAX CARRIER* ¨ UPS ¨ OTHER DATE REQUIRED TIME *ORDERS SHIP UPS GROUND ON THE FOLLOWING DAY UNLESS SPECIFIED. EMAIL PATIENT INFORMATION PROSTHETIST (NAME, TITLE) REQUISITIONER PATIENT (FIRST, LAST) WEIGHT ¨ LBS ¨ KG AMP LEVEL ¨ AK ¨ BK ¨ HIP ¨ KNEE ¨ SYMES K3 IMPACT LEVEL: ¨ LOW ¨ MODERATE ¨ HIGH PART ID SIDE VL VL L R SHELL COLOR HOUSING J B T C J B T C Caucasian Tan Brown Jet Black K3 C T B J MOUNTING SIZE WIDTH EN EN SE S E Electric Green Silver OPTIONS: ¨ Shelltread N W E S 25-30cm N W Wide Narrow W N IMPACT LEVEL: ¨ LOW ¨ MODERATE ¨ HIGH PART ID SIDE V V L R SHELL COLOR J B T C J B T C Caucasian Tan Brown Jet Black MOUNTING SIZE ALX EN C T B J ALX EN Endo Exo OPTIONS: ¨ Shelltread ¨ Exo Alignment Tool ¨ Exo Block WIDTH N W EN ALX 21-30cm N W Wide 24-30cm only W Narrow N 044 FRM FOF NA 160112 EMAIL COMPLETED ORDER FORM TO: orders@college-park.com 27955 College Park Dr, Warren, MI 48088, USA TOLL FREE 800.728.7950 FAX 586.294.0067 ON THE WEB www.college-park.com
