Townsend Design Custom Functional Braces

LOCKING BRACE Trigger Lock or Drop Lock braces for sever instabilities

Full Shell:

Combined Instabilities (with secondary distal thigh band
ACL — Do you want a distal thigh strap? Yes No

Premiere:

Combined Instabilities (with secondary thigh band)
ACL — Do you want a distal thigh strap? Yes No

Hinges:

Trigger Lock; w/ condylar pads? Yes No
 Trigger Lock with Release; w/ condylar pads? Yes No
 Drop Lock Hinge (full shell model only); ball retainers? Yes No

Set brace to lock at casted position; Set lock at degrees

COLOR:
OR Townsend Fabric#
OR Fabric Inlay -1 yard from patient

Length: 14" 16" Other inches Straps: 4 5 Straps (16" only)

Color & Fabric Options For All Non-Painted Braces
EXTENSIONS STOP
Check box if you DO NOT want lateral attachment to go inside the shell (recommended for prominent fibular head). 5" (standard) Other
Extensions Stop Kit
OPTIONS (added charge)
EXTENSIONS STOP
Flexion Stop Kit
Motorcross Knee Protector Undersleeves (black)
1/8" Atrophy Thigh Sleeve
1/16" Comfort Thigh Sleeve
Neoprene: 18" 22"
Polyprene: (18" only) 		5" (standard) Other
Extensions Stop Kit
BRACE REPAIRS ONLY

Adjustment — Indicate repairs needed in Special Instructions.
Remold — A new cast must be sent with the brace. Indicate where the brace needs remolding in the Special Instructions section or use a wax pencil to make marks directly on the brace. Service includes refurbishing.
Refurbish — New straps, loops, chafes, hinge covers, hinge realignment. Should we replace shell pads, too (added charge)? Yes No
Refurbish and Repaint (Painted Braces); Repplace shell padding too? Yes No

Roll casting material 9 to 10" above & below knee center; cast with the patient's leg at full extension, non-weight bearing, with the foot dorsiflexed. PLEASE cut cast off posterior aspect of the leg.

The information you provide us (below) IS CRITICAL to achieving the best outcome.
Patient Age Sex Height Weight
Occuption/Activities Leg: Left Right
Ligament: ACL PCL MCL LCL
Meniscus Damage: Medial Lateral
Surgeries/type Date of Last Surgery
Physician
Casted By
Phone#
INSTRUCTIONS (Special considerations)
To confirm cast accuracy, please provide the M-L width of the knee at knee center Date you will fit this brace:
Billing PO , Townsend Account# or bill to:





SHIPPING (We do not ship new braces directly to patients)




Next Day Air
2 Day Air
Ground

(If no preference is given, brace will ship 2 Day Air)