Prosthetics Lower Extremities - Kinetech Medical

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C-Leg®compact / C-Leg® Leg Prosthesis System · Patient Data
Fax to the addresses of our branches throughout
the world, which are listed at the end of this catalog.
Billing Address
Shipping Address (if different than billing address)
Customer no.
Company
Address
Customer no.
Company
Address
Orthopedic technician
Com.
Prosthesis user
Name __________________________________________
Age ____________________________________________
Sex male female
Weight _______________________________________kg
Size _________________________________________ cm
Knee – floor___________________________________ cm
Socket – floor _________________________________ cm
Foot size _____________________________________ cm
Prosthesis user - Mobility Grade
Mobility Grade 2
Mobility Grade 3
Mobility Grade 4
Amputationsniveau
Knee Disarticulation
Transfemoral
Hip Disarticalation
Color of footshell beige light brown
Side of amputation left right
Bilateral amputation yes no
Osseointegration yes no
Initial fitting with a C-Leg®compact / C-Leg®
Follow-up fitting with a C-Leg®compact / C-Leg®
The C-Leg®compact / C-Leg® leg prosthesis system is only offered as a complete system.
The General Terms and Conditions of Otto Bock HealthCare GmbH apply.
Date _____________ Place _____________________________
Signature ___________________________________
272 Otto Bock HealthCare GmbH | Prosthetics – Lower Extremities | www.ottobock.com