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!
 
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
 
feetinches
* 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 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 Tiger Orange Snake Camouflage Metallic Stars and Stripes Flat Stars and Stripes Carbon Fiber
MEASUREMENT INFORMATION:
 
Measured by:

If you have an .AOP 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 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
 
(Measurement range: 12½” – 38 1/8”)
Short Thigh
cm
  (Measurement range: 31.8 cm – 97 cm)
Short Calf
cm
  (Measurement range: 26.125 cm – 66.5 cm)
Standard Calf
inches
  (Measurement range: 10¼” – 26¼”)
Knee Joint Angle
Condyle One
Condyle Two
Note: check both short and standard measurments for ski boot option. Best to measure with ski boot on.
FEATURES:
 
a. Note: *standard option on DEFIANCE® III
Suede Liners / Pads
Chamois Liners / Pads
Neoprene Suspension Strap Kit
Swooping Thigh (not available on Short Thigh)*
Swiveling Strap Tabs*
Legend Square Strap Ends
Metal Caps - PowerCaps (recommended for contact sports)
Sili-Grip Strap Pads
Reinforced Carbon Composite Frame (recommended for contact sports)

Installed Extension Stop 
Installed Flexion Stop 
ACCESSORIES:
 
Note: There is an extra charge for accessories
Tru-Pull Advanced Attachment Floam Condyle Pads
Lycra Suspension Sleeve Pinch Guard (Calf)
Armor Impact Guard Sports Brace Cover
Full Extension Lockout Stop Air Condyle Kit
Neoprene Suspension Sleeve Atrophy Pad Kit
High Strength Stainless Steel Gears Sili-Grip Strap Pad Kit
COMMENTS: