Order AK by Measurement

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Name:

Email:

Phone:

Company/Branch :

Address :

Shipping Method :

Patient Last Name only :

Side :

Right

Left

Sex :

Male

Female

Activity level :

Type of Carving:

Positive carving

Diagnostic

Template:

Distal end :

Bulbous

Conical

Square

M-L of distal end :

Length :

Flexion :

Abduction :

Measurement at 0" :

Measurement at 2" :

Measurement at 4" :

Measurement at 6":

Measurement at 8" :

Measurement at 10" :

Measurement at 12" :

Special Instructions :

Thank you for submitting your AK by Measurement order. If you have any questions regarding your order, please feel to contact us at 800.470.1188

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