Order form - Makstride prosthetics

BioStride Series
BioStride
Series
Product
Orders
For expedited processing of new product orders, please complete this form and submit it by fax to 661.864.7512, or scan this document
and E-mail it to turpin@makstride.com. For verbal orders, please call 661.325.3338.
Patient Name ___________________________________
Select BioStride Series Model
Patient Profile
Male
Female
Which definition best describes this patient?
New Amputee
1-3 Year Amputee
4+ Years
Amputation Level:
Amputation Side:
AK
Left
BK
Right
Base Code Recommendation: L-5987
Code: L-5986 or L5984
Optional Male Pyramid Build Height Clearance: 7 5/16”
Female Pyramid Build Height Clearance: 7 11/16”
Bilateral
Age: _________ Height: __________ Weight: _________
Foot Length: _______ cm Shoe Heel Height: ___________
(Keels available in 22-31cm) (Maximum heel height 1 1/4”)
Foot Shell
Light Flesh Tone
UltraStride (bifurcated shank)
K3: 70-310 lbs. & K4: 70-265 lbs.
Dark Flesh Tone
Everyday Routine Activity Level (please select one)
K2 (variable cadence, navigates most moderate
environmental barriers)
K3 (variable cadence, navigates environmental barriers
including stairs, steps, inclines, and declines, uneven terrain)
K4 (variable cadence, navigates environmental barriers
including running, hiking, skiing, tennis, bicycling)
K4 Extreme (variable cadence, navigates environmental
barriers including lifting/pushing heavy loads or high impact
activities. This includes weight lifting, cross training,
construction work, basketball, soccer, motocross)
If we have a question regarding this order, please
provide the name/number of the person we should
contact:
PO # ____________________________________________
ActiveStride
K3: 70-310 lbs. & K4: 70-265 lbs.
Base Code Recommendation: L-5980
Optional Code: L-5986 or L5984
Male Pyramid Build Height Clearance: 7 5/16”
Female Pyramid Build Height Clearance: 7 11/16”
NaturalStride (bifurcated shank)
K3: 70-500 lbs. & K4: 70-385 lbs.
Base Code Recommendation: L-5981
Optional Code: L5986 or L5984
Male Pyramid Build Height Clearance: 5 7/8”
Female Pyramid Build Height Clearance: 6 1/4”
K2 ComfortStride
K2: 70-500 lbs.
Base Code Recommendation: L-5972
Optional Code: L-5986
Male Pyramid Build Height Clearance: 5 7/8”
Female Pyramid Build Height Clearance: 6 1/4”
Select Pyramid (Not rotation adjustable)
Male
Female
Practitioner: ______________________________________
Phone: __________________ Fax: __________________
Email: _________________________________________
Additional Accessories (Additional charges apply)
Light Flesh Tone Foot Shell
Dark Flesh Tone Foot Shell
Foam Calf Shank Cover (8-inch length)
Additional Spectra Sock ___1 ___ 2 ___ 3
Bill To:
Company Name: ___________________________________
Shipping Preference (Additional charges apply)
Ground
3 Day
2 Day
Next Day
(If no preference is indicated, products will ship UPS ground)
Street Address: ____________________________________
City: _____________________State:______ Zip: _________
Ship To: (complete this section if different from billing address)
Company Name: ___________________________________
Street Address: ____________________________________
45 Day Risk Free Evaluation Period and Warranty Coverage
Makstride Prosthetics offers a 45 day unrestricted return policy for
risk free comparison and evaluation. If you or the patient are not
satisfied with the performance and functional benefits of the foot,
you can seek assistance from Makstride Prosthetics staff to
achieve the desired outcome, or return the product for credit.
NO REFUNDS AFTER 45 DAYS.
36 month repair/replacement warranty (please refer to
warranty/return documents for qualifications.)
City: _____________________State:______ Zip: _________
Makstride Prosthetics – 3970 South 1540 East, St. George, Utah, 84790 Phone: 661.325.3338 Fax: 661.864.7512