Thank you for your interest in Alpha DESIGN® Liners. Complete this form electronically to receive a savings.
Alpha DESIGN® AK 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.
I do not want to be contacted; I am comfortable with Ohio Willow Wood using their discretion in the design of 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: Cushion liners will ship within 3 days, and locking liners within 4 days of verification of this completed form)
UPS Red
UPS Blue
UPS Ground
Other
YES, I'd like to complete this Alpha DESIGN
Liner by webinar

2. Patient Information

a. Amputation Side:
Left
Right
b. Amputation Level:
AK
Knee Disarticulation
c. Limb Length (I.T. to distal end of limb):
d. Circumference of limb at 12” proximal to distal end
(or highest point obtainable):
e. Height:
Weight:
Age:
f. Patient ID
Please make sure to write the patient ID on the cast.
Ohio Willow Wood
15441 Scioto Darby Road
Mt. Sterling, OH 43143

3. Liner Information:

a. Quantity of DESIGN Liners:
1
2
Other
b. Liner Type:
Cushion
Locking
c. Outer Fabric Cover(select one only; Buff color only):
Original
MAX
Spirit
Please note all liners will have outer fabric color of Buff.
d. Inner Comfort Cuff: This is an add-on feature and costs
$25 extra. Inner fabric will follow brim angle. Ohio Willow Wood
recommends that inner fabric extend 2" below socket brim.
Yes
No
If yes, please provide fabric heights for:
Medial:
Lateral:
e. Liner Umbrella Size (for Medium and Medium Plus sizes
ONLY. All other liners are made with the corresponding sized umbrella.):
Standard (recommended for most liners)
Small
f. Pre-Stretch liner:
Yes
No

4. Casting Marks:

The following marks must be indicated on the cast:
Knee Disarticulation:
•Lateral Distal Femur Condyle
•Ischium
•Medial Distal Femur Condyle
•Distal Femur
•Scar/Invagination
Standard AK:
•Lateral Distal Femur
•Ischium
•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.

5. Notes:

Please note: A cancellation fee 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 Ohio Willow Wood.
All specifcations and pricing are subject to change without notice.
© 2005 Ohio Willow Wood