ORTHOTIST INFORMATION

Name: ____________________________________________ Company: __________________________________________

Phone: ____________________________________________ Email: ______________________________________________

Patient name: ______________________________________ DOB: ______________________________________________

Send order form to Paul Coleman: pcoleman@opchealth.com.au

OPC HEALTH

Distributed by OPC HealthPaul Coleman - Prosthetics & Orthotics Product ManagerT: 03 9681 9666 M: 0411 959 462 E: pcoleman@opchealth.com.au www.opchealth.com.au

®ALLELES Design Studio ORDER FORM

PO ____________

BILLING INFORMATION

Name: _____________________________________________

Company: __________________________________________

Address: ____________________________________________

Suburb: ______________ State: _____ Postcode: _______

Country: ____________________________________________

1. SELECT DESIGN:

SHIPPING INFORMATION

Name: _____________________________________________

Company: __________________________________________

Address: ____________________________________________

Suburb: ______________ State: _____ Postcode: _______

Country: ____________________________________________

Digital Rococo

Exius 2.0

Exo

Fadilah

Flora

Future Plaid

Gaia

Geomecon

Glide

HI-TOP

HIFI

Imperialist

Janz Pro

Jennings

John-Paul

Khloris

L750

Merovingi

Monarch

Moto GP

MTL

Mythic

Nouveau

OM

Paisley

Palms

Paradigm

Pines

Roe 2.0

Roth

Royale

Salt M2

SALT Pro

Sochi

Stealth

Steen

Victorian

Wings

Allens

Alpine

Apollo

Baller

Bloom

Deener

Digi Camo

2. COVER LENGTH (inches):

10” 10.5” 11” 12” 12.5” 13” 13.5” 14” 14.5” 15” 15.5” 16” 16.5” 17” 17.5” 18” 18.5” 19” 19.5” 20”

3. COVER WIDTH (inches):Small (12-14 inches)

Standard (14-16.5 inches)

Large (16.5-18 inches)

4. LEFT or RIGHT:Left Leg

Right Leg

5. TOP SHAPE:Arch (for AK)

Dip (for BK)

6. BACK SHAPE:Sport Cut (easier to don/doff)

Racer Back (more coverage)

7. MAIN COLOUR 8. DETAIL COLOUR

9. STRAP COLOURBlack (default - no charge)

Tan (additional charge)

Red (additional charge)

Blue (additional charge)

10. ADJUSTMENTSNo

Polycentric / 4 Bar Knee

Through Knee (TK)

Rotational Plasty

Symes

Release Valve

Revo Socket

Osseo (AK only)

ANYTHING ELSE WE SHOULD KNOW?__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

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14k Gold

Army Green

Baby Blue

Baby Pink

Baby Yellow

Black

Charcoal

Cobalt

Forest Green

Grey Green

Lime Green

Maroon

Navy

Nude 1

Nude 2

Nude 3

Nude 4

Nude 5

Orange

Purple

Racecar Yellow

Red

Rose Gold

Seafoam

Silver

Spanish Gold

Teal

White

14k Gold

Army Green

Baby Blue

Baby Pink

Baby Yellow

Black

Charcoal

Cobalt

Forest Green

Grey Green

Lime Green

Maroon

Navy

Nude 1

Nude 2

Nude 3

Nude 4

Nude 5

Orange

Purple

Racecar Yellow

Red

Rose Gold

Seafoam

Silver

Spanish Gold

Teal

White

®ALLELES Design Studio ORDERING INSTRUCTIONS

ABOVE KNEE FIT1. Length: measure from the apex of mechanical knee to the top of footshell.2. Width: measure the circumference of the widest part of sound limb.3. Gap: recommended to leave 1/2-1 inch gap between top of foot shell to bottom of cover.

BELOW KNEE FIT1. Length: measure from lowest dip of socket to the top of footshell.2. Width: measure the circumference of the widest part of socket.3. Gap: recommended to leave 1/2-1 inch gap between top of foot shell to bottom of cover.

DIP TOPRecommended for Below Knee Prostheses.

ARCH TOPRecommended for Above Knee Prostheses.

SPORT BACKEasiest to take on and Off. Additional Space is ideal for larger prosthetic components as well as accommodating dynamic foot and ankle motion.

RACER BACKMore Coverage. Extra tabs near the ankle strike a fine balance between function and coverage.

OPC HEALTH

Distributed by OPC HealthPaul Coleman - Prosthetics & Orthotics Product ManagerT: 03 9681 9666 M: 0411 959 462 E: pcoleman@opchealth.com.au www.opchealth.com.au

®ALLELES Design Studio COLOUR SWATCHES

OPC HEALTH

Distributed by OPC HealthPaul Coleman - Prosthetics & Orthotics Product ManagerT: 03 9681 9666 M: 0411 959 462 E: pcoleman@opchealth.com.au www.opchealth.com.au

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