Modify A BK
Use this page to communicate to us how you would like your BK prosthesis modified.
General Information
Contact Name:
Company Name:
Depth of PTB
Length from MPT to distal end
Distal tibia buildup
Anterior View
Posterior View
Medial View
Lateral View
Fibular head buildup
Patient Name:
Age:
Height:
Weight:
Activity level:
Casted over a liner?:
Cast Modification Information
Tibial crest buildup
Posterior Shelf Choice:
Special Instructions
Level of shelf:
Depth of shelf:
PML
Special Instructions
To print a copy for your records, use the print function on your browser before clicking submit. (File --> Print --> Options --> As laid out on screen)
110 Industrial Road
Fulton, MO 65251800.470.1188
Fulton, MO 65251800.470.1188Volume
change:
# of Ply:
Circumference Measurements
Level
0"
2"
4"
6"
8"
10"
12"
Mid patella level
M-L
A-P
Liner thickness:
PO #::
