Request CAD-CAM Order
Contact Phone Number
Ship to Address
City, State & Zip
Date Requested By
Preferred Shipping Method
Type & Side Requested-required
Side Requested-required ( One entry per side for bi-lateral orders)
Material Requested for Test Socket
Distal End Attachment Type
Please enter type if "Other" is selected
Please enter your shipper number if requested method.
If "Yes" please indicate amount to be reduced by below.
Ischium or Perineum to Distal End
Residual Limb Measurement
If "Other" please list style requested.
Thank you for your order.