Thank you for your interest in Alpha DESIGN® Liners. Complete this form electronically to receive a savings.
Alpha DESIGN® BK Liners Order Form
Phone: 1-800-848-4930
Please complete this form and then press the "Print" button at the bottom. Please include one copy with cast of residual limb only. Missing information may delay your order. Please fill out form accurately and with care. Credit will not be issued due to order forms completed with inaccurate information or incomplete forms. Do NOT cast over a liner. For bilateral amputees, please complete separate forms for each residual limb.
To download a .pdf version of this form, click here.
Please have a DESIGN Technician contact me before making this liner.
Yes
No

1. Ship To/Bill To Information:

Account No.
P.O. No.
Ship To:
Company Name
Address
City/State/Zip
Phone No.
Fax No.
E-mail Address
Prosthetist
Bill To: Same as Ship To       Different than Ship To
Company Name
Address
City/State/Zip
Phone No.
Fax No.
Shipping Options: (Lead Times: classic gel cushion liners - 3 days, classic gel locking liners - 4 days, & all hybrid gel liners - 5 to 7 days of verification of this completed form.)
UPS Red
UPS Blue
UPS Ground
Other
YES, I'd like to view and assist in the design of this
custom liner with an online webinar session.

2. Patient Information

a. Amputation Side:
Left
Right
b. Limb Length (MPT to distal end of limb):
c. Circumference of limb at 16” above distal end
(or highest point obtainable):
d. Patient ID
Please make sure to write the patient ID on the cast.
The Ohio Willow Wood Company
15441 Scioto Darby Road
Mt. Sterling, OH 43143
P: 800.848.4930
F: 740.869.4374

3. Liner Information:

a. Quantity of DESIGN Liners:
1
2
Other
b. Liner Type:
Cushion
Locking
c. Gel Type:
Classic
Hybrid
d. Outer Fabric Color:
Buff
Green/Gray (Original and Spirit only)
Brown (Original and Spirit only)
Gray (Select only)
e. Outer Fabric Cover:
Original
MAX
Spirit
Select
f. Liner Umbrella Size (for Medium and Medium Plus sizes
ONLY. All other liners are made with the corresponding sized umbrella.):
Standard (medium through extra large plus sizes; recommended for most liners)
Small (small through medium plus wide sizes)
g. Pre-Stretch liner:
Yes
No

4. DESIGN Liner Type:

Standard
Symes

5. Casting Marks:

The following marks must be indicated on the cast:
•Fibula Head
•Distal Fibula
•Distal Tibia
•Patella
•MPT
•Missing marks may result in incorrect gel thicknesses and/or delay the order.
•Please click here for examples of how to mark the cast desired
gel thickness and other information.

6. Notes:

Please note: A cancellation fee of $75 will be charged for Alpha DESIGN Liner orders cancelled after order forms, casts, and/or shape files have been received and processed.

Alpha is a registered trademark of The Ohio Willow Wood Company.
All specifcations and pricing are subject to change without notice.
© 2012 WillowWood