EASY - Complete at time of fitting.
If BILATERAL, it is okay to use the same form for both orthoses.

* these values have to be filled out.  

To print-off Warranty Card Click here

Date Fitted

Serial No. Left

Serial number is located on inside anterior support – an alpha character followed by 4-6 numbers. If bilateral, insert serial number for both LEFT and RIGHT.

Serial No. Right

Product Fitted

Size

Patient Name/ID

Facility Name

Facility Address

City

Country

State/Province/
Territory

Zip

Orthotist

Phone

Purchased From**

Your purchase order #

**Please contact the company you have indicated to obtain return authorization.