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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):