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Custom Bracing Form

* Indicates required fields.
BILL TO:
  
* Account #
* Account Name
* P.O. #
* Contact
* Address
* City
* State
* Zip
* Phone
* Email
  * Email used for confirmation only!
Are you a Hanger Account?
 Yes No
 
SHIPPING INFORMATION:
 Same as "Bill To" address
Account Name
* First Name
* Last Name
* Address
* City
* State
* Zip

UPS Red (overnight) UPS Blue (2-day air) UPS 3 Day
UPS Ground
Other

PATIENT INFORMATION:
  
* First Name
* Last Name
* Age
* Height
 feet inches
* Weight
 pounds
Measurements Taken On:
 Right Left Reverse
Measurements Type:
 New Brace Re-measurement
PRODUCT SELECTION:
  
Frame:
DEFIANCE III DEFIANCE
Strapping:
ACL PCL CI
Hinge:
FourcePoint Female Fource Adjustable OA Standard
Standard (slide shield) Droplock
Affected Compartment:
Adjustable OA ONLY!

Medial Lateral
Degrees of Correction:
COLORS:
  
Please select a thigh cuff color and a calf cuff color. To make the brace a one color brace, select the same colors for thigh and calf.
Defiance Color Chart .

Note: gradient can only be with 2 flat colors
Thigh Cuff – Black Flat
Calf Cuff – Black Flat
 Thigh Cuff – Red/White/Blue Flat
Calf Cuff – Red/White/Blue Flat
Thigh Cuff – Gold Metallic Gradient
Calf Cuff – Black Metallic
 Thigh Cuff – Light Blue Flat Gradient
Calf Cuff – White Flat

Thigh Cuff
Calf Cuff
Note: Gradient can only be with 2 flat colors
Special color(s:)
GRAPHICS:
  
Note: There is an extra charge for graphics. You may choose a color OR a graphics option, but not both.
Tiger Red Butterfly Leopard Blue
Tiger Orange Snake Camouflage
Stars and Strips Metallic Stars and Stripes
MEASUREMENT INFORMATION:
  
Measured by:
If you have an .AOP or .FSN (Hanger accounts only) please upload here and skip to OPTION section below. Note: File names can only be 25 or less characters and cannot contain symbols like &, $, #, *, |, \, /, :, ;. Please only use ONE dot to separate the file name from the file type.
.AOP or .FSN File:
* the file name should not contain any commas or spaces
If you have CCMI measurements, please continue...
CCMI Mark II CCMI Mark III
Standard Thigh
 inches
(Top Thigh Strap)
Short Thigh
 cm
  (Bottom Thigh Strap)
(26" inseam or less)
Short Calf
 cm
  (Top Calf Strap)
(26" inseam or less)
Standard Calf
 inches
Knee Joint Angle
Condyle One
Condyle Two
  (Bottom Calf Strap)
Note: check both short and standard measurments for ski boot option. Best to measure with ski boot on.
Thigh Contours 1. 2. 3. 4. 5.
Calf Contours 1. 2. 3. 4. 5.
OPTIONS:
  

Note: * not available on DEFIANCE III. ** represents standard option on DEFIANCE III
Suede Liners / Pads
Chamois Liners / Pads
Pneumatic Liners / Pads*
Swooping Thigh (not available on Short Thigh)**
Swiveling Strap Tabs**
Reinforced Frame (DEFIANCE Extra)
Legend Square Strap Ends
PowerCaps – metal strap caps (recommended for contact sports)
Sili-Grip Strap Pads

Installed Extension Stop

Installed Flexion Stop

ACCESSORIES:
  

Note: There is an extra charge for accessories
Tru-Pull Advanced Attachment Floam Condyle Pads
Lycra Undergarment Calf Pinch Guard
Pneumatic Condyle Kit Neoprene Suspension Kit
Impact Guard Sports Cover
Full Extension Lockout Stop Air Condyle Pads
Neoprene Undergarment Atrophy Pad Kit
High Strength Stainless Steel Gears
COMMENTS:
  


  

 
 
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