7

9 10

8

Please mark hip joint locationon cast.

Use a firm table and a knee support when taking measurments.

Orthotist

Phone ( ) Fax ( )

Ship/Bill to Address

City State Zip

Date PO #

Patient Name

Age Weight lbs.

Male/Female Height ft. in.

Diagnosis Level

Fill out all 10 measurement boxes on this form. Measurements are needed even when you are sending a cast. If you need a custom design or expert advice please let us know.

Cast Included No Cast

16

5

4

2

3

TOP OF JACKET

TROCHANTERWIDTH

WAIST

Spinal Support

Bivalved Body Jacket Posterior Shell Only Buttocks Pad Only Metal Only Permanently Attached Detachable

Hip Joints

Conventional

Abduction

Hip Joint Upper Bars Regular Extra Long

Lower Bars Regular Extra Long

Plastic Kydex

White Black Tan Gray Red Blue

Polypropylene (Extra Charge) Metal on Top Metal Under

Call for available colorsChest Strap

White Black Tan Rainbow With Optional Padded Front Panel

Extra Abdominal Strap White Black Tan Rainbow

With Optional Padded Front PanelConnectors and Plates Plates

Standard Thickness Heavy Duty (large only) Optional

Connector Type Standard

Easy Alignment OptionalPelvic Band

Regular Light Duty

Innerface Liner Pink Plastizote

Single Layer Double Layer

White Aliplast Single Layer Double Layer

Contracture Yes No

IMPORTANT: Measurement #1 is very crucial for a good fit. Ultimately the measurement in box #1 determines the inside width of the body jacket. Measurements In: Centimeters Inches

Measurements

Options

Becker ISO-Metric RGO Customer Order Form

Rev. 4/18

Push Button

Becker Orthopedic - 574 Robbins Dr. - Troy, MI 48083 Phone: 248-588-7480 - Fax: 248-588-4555

328 Iso-Metric Pelvic Section Only 328-K Iso-Metric RGO with KAFOs 328-A Iso-Metric RGO with AFOs

Requested Delivery Date(Standard lead time 10-14 days):