2711 Cartwright Road
Missouri City, TX 77459
Ph: 281.403.0117
Fax: 281.403.0113
dycormfginc@comcast.net
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Prosthetic Feet
Cap Liners
Central Fabrication
MF 80
Prosthetic Hip
Components
ADL Coupling Specifications
Keel Deflection Chart
Pylon Wall Thickness Chart
L Codes
TRANS-TIBIAL LINER
Cap Liner Order Form
Custom Orders Please Allow Two Weeks for Delivery.
Customer Information
Customer:
E-Mail:
PO#:
Address:
City:
State:
Zip Code:
Telephone:
Fax:
Patient's Name:
Weight:
K Level:
Right / Left
Right
Left
Geriatric / Non Geriatric:
Geriatric
Non-Geriatric
TRANS-TIBIAL LINER
Color: (liner)
White
Beige
Coral
Torquoise
Brown
Salmon
Zone Padding:
(optional)
Yes
No
Location:
Distal Padding:
(optional)
Extra Soft
Soft
Medium
Firm
Thickness:
4
5
6
Elastic / Inelastic
(frame)
Elastic
Inelastic
What We Need From You:
Option 1
Option 2
A modified check socket. We will reduce it 5° and lengthen 5°. We will send back the liner and you can roll it on the check socket for fabrication. Proximal trim to support non-weight bearing tissue.
Unmodified cast along with the patient's measurments. Please draw the trim line. We will fill and modify cast. We will reduce circumference by 5° and
lengthen 5°. We will send back a liner.
Please Note:
If a modified positive is sent to us we might bi-valve the positive.
Will this be okay?
Yes
No
DISCLAIMER
WARNING
. Contact of CAP liner material with the skin may cause irritation. Persons with known susceptibility to dermatitis or broken skin should aviod contact with this material. Anyone who develops skin irritations after contact with this material should discontinue use immediately and consult a physician. It is the responsibility of the attending Prosthetist to determine the safety, suitability and adequancy of this product. Follow up on a routine basis is recommended to monitor skin conditions, wear and replacement as needed.
Warranty.
CAP liners are available from very soft and fragile to firm and durable. It is the responsibility of the attending Prosthetist to correctly match the softness and durability with the clinical requirement of each individual wearer. Defects in workmanship or materials are covered for a period of three (3) weeks from date of purchase and are subject to our review and inspection. CAP liners are a custom product. They are not subject to restock or return. An inspection and photographic record is kept on all CFS products for quality assurance.
I have read and agree with the Warning and Warranty
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