Order forms Mechatronic knee joint systems Genium X3 - Genium - Cleg - Kenevo
Genium
Genium X3 Bionic Prosthetic System Billing Shipping (if different from billing adress) Customer no. Order no. Orthopedic technician Com. Prosthesis user Name Age Gender male female Weight kg Size Foot size Side of amputation left right bilateral Mobility Grade Mobility Grade 3 Mobility Grade 4 Amputation level Knee Disarticulation Transfemoral Hip Disarticulation / Hemipelvectomy Initial fitting of prosthesis (patient has never been fitted with a prosthesis before). Follow-up fitting Prefitting with: 3C98* / 3C88* C-Leg 3C96* / 3C86* C-Leg compact 3B1 / 3B1=ST Genium 3B5-X3 / 3B5-X3=ST Genium X3 Prefitting with: Additional component 1 Secondary Fitting 2 Manufacturer/Type/Name ( 1 Order additional components only 2 Order an additional knee joint)
Genium X3 Bionic Prosthetic System Knee joint (minimum order quantity: 1) qty. 3B5-2 Genium X3 Bionic Prosthetic System, Pyramid Adapter qty. 3B5-2=ST Genium X3 Bionic Prosthetic System, Screw Top including following additional components: 757L16-3 Adapter, 4E60 Inductive Charger, 4H101/4H102 Knee flexion stops Electronic Tube Adapter (minimum order quantity: 1) qty. 2R19 AXON Tube Adapter Protector (minimum order quantity: 1) qty. 4X193 Protector (graphite black) qty. 4X900 Protector (umbra grey) Warranty 3 years 6 years Foot parts* qty. 1D35 Dynamic Motion qty. 1E57 Lo Rider qty. 1C63 Triton Low Profile 3) qty. 1C30 Trias qty. 1C60 Triton qty. 1C64 Triton Heavy Duty 3) qty. 1C40 C-Walk qty. 1C61 Triton Vertical Shock qty. 1E56 Axtion qty. 1C62 Triton Harmony Color of footshell beige light brown 4 Shape of footshell slim 4 normal ( 4 Not available for all foots and/or sizes. Please visit our homepage for more information.) If foot is already existing: current prosthesis foot (type, side, size) Connection components Accessories qty. 4R57 Rotation Adapter qty. 4R57=ST Rotation Adapter with Thread qty. 4R104=60 Double Adapter, movable qty. 4R104=75 Double Adapter, movable qty. 4R72=32 Double Adapter qty. 4R72=45 Double Adapter qty. 4R72=60 Double Adapter qty. 4R72=75 Double Adapter qty. 4R84 Double Adapter qty. 4R40 Torsion Adapter qty. 4R118 Adapter Plate qty. 4X350-X3 Remote Control qty. 4E60 Inductive Charger (additional) qty. 757L16-3 AC Adapter (additional) qty. 4R43 qty. 4R89 qty. 4R41 qty. 4R111=N qty. 4R111 qty. 4R116 qty. 4R119 Lamination Anchor with Threaded Connector (3-prong) Lamination Anchor with Pyramid Adapter (3-prong) Lamination Anchor with Pyramid Receiver (3-prong) Lamination Anchor with Threaded Connector (4-prong) Lamination Anchor with Pyramid Receiver (4-prong) Lamination Anchor with Pyramid Adapter (4-prong) Lamination Anchor with angled arm qty. 4R111=T Lamination Anchor with Pyramid Receiver (4-prong) 3) qty. 4R116=T Lamination Anchor with Pyramid Adapter (4-prong) 3) qty. 4R119=T Lamination Anchor with angled arm 3) qty. 4WR95=1 qty. 4WR95=2 Lamination Anchor with Pyramid Adapter and angled arm Lamination Anchor with Pyramid Adapter qty. 4H104 Knee flexion stop (22,5 ) qty. 60X5 BionicLink PC qty. 4X1 X-Soft Note: X-Soft can be upgraded for free via http://ottobock.com/en/datastation 4) recommended system combination, because water & corrosion resistant component * Please use a seperate oder form for purchase. Regarding further information please refer to the catalogue 646K2=EN or visit www.ottobock.se The Genium X3 Bionic Prosthetic System is only offered as a complete system. The General Terms and Conditions of Otto Bock Healthcare apply. Ottobock Orderform Genium x3 110421-EN-01-1510 Technical modifications and printing errors reserved. Date Place Signature
Genium Bionic Prosthetic System Billing Shipping (if different from billing adress) Customer no. Order no. Orthopedic technician Com. Prosthesis user Name Age Gender male female Mobility Grade Mobility Grade 2 Mobility Grade 3 Mobility Grade 4 Weight Size Foot size kg Amputation level Knee Disarticulation Side of amputation left right bilateral Transfemoral Hip Disarticulation/ Hemipelvectomy Initial fitting of prosthesis (patient has never been fitted with a prosthesis before). Follow-up fitting Prefitting with: 3C98* / 3C88* C-Leg 3C96* / 3C86* C-Leg compact 3B1 / 3B1=ST Genium 3B5-X3 / 3B5-X3=ST Genium X3 Prefitting with another knee joint Additional component 1 Secondary Fitting 2 ( 1 Order additional components only 2 Order an additional knee joint) (Manufacturer/Type/Name) Ottobock 110417=EN-01-1510
Genium Bionic Prosthetic System Knee joint (minimum order quantity: 1) St. 3B1-2 Genium (Volcano Shadow) St. 3B1-2=ST Genium (Volcano Shadow), for long residual limb St. 3B1-2=9.2 Genium (Desert Pearl) St. 3B1-2=ST-9.2 Genium (Desert Pearl), for long residual limb including following additional components: 757L16-3 AC Adapter, 4E60 Inductive Charger, 4H99 / 4H100 Knee flexion stop, 4X259 Installation Ring for Inductive Charger Electronic Tube Adapter (minimum order quantity: 1) qty. 2R20 AXON Tube Adapter qty. 2R21 AXON Tube Adapter (Torsion Unit) Warranty 3 years 6 years Foot parts* qty. 1M10 Adjust qty. 1E56 Axtion qty. 1C62 Triton Harmony qty. 1D35 Dynamic Motion qty. 1E57 Lo Rider qty. 1C63 Triton Low Profile qty. 1C30 Trias qty. 1C60 Triton qty. 1C64 Triton Heavy Duty qty. 1C40 C-Walk qty. 1C61 Triton Vertical Shock Color of footshell beige light brown 3 Shape of footshell slim 3 normal ( 3 Not available for all foots and/or sizes. Please visit our homepage for more information.) If foot is already existing: current prosthesis foot (type, size, serial number) Connection components qty. 4R57 Rotation Adapter qty. 4R57=ST Rotation Adapter with Thread qty. 4R104=60 Double Adapter, movable qty. 4R104=75 Double Adapter, movable qty. 4R72=32 Double Adapter qty. 4R72=45 Double Adapter qty. 4R72=60 Double Adapter qty. 4R72=75 Double Adapter qty. 4R40 Torsion Adapter qty. 4R118 Adapter Plate qty. 4R43 Lamination Anchor with Threaded Connector (3-prong) qty. 4R89 Lamination Anchor with Pyramid Adapter (3-prong) qty. 4R41 Lamination Anchor with Pyramid Receiver (3-prong) qty. 4R111=N Lamination Anchor with Threaded Connector (4-prong) qty. 4R111 Lamination Anchor with Pyramid Receiver (4-prong) qty. 4R116 Lamination Anchor with Pyramid Adapter (4-prong) qty. 4R119 Lamination Anchor with angled arm qty. 4R76 Double Adapter qty. 4R78 Double Adapter Foam cover Protector qty. 3S26 Standard Foam Cover qty. 4X880=... (S,M,L) Genium Protector Accessories qty. 4X350 Remote Control qty. 757L16-3 AC Adapter (additional) qty. 4E60 Inductive Charger (additional) qty. 4H103 Knee flexion stop (22,5 ) qty. 60X5 BionicLink PC qty. 4X258 Installation Tool for Inductive Charger qty. 4X1 X-Soft Note: X-Soft can be upgraded for free via http://ottobock.com/en/datastation * Please use a seperate order form for purchase. Regarding further information please refer to the catalogue 646K2=EN or visit www.ottobock.se The Genium Bionic Prosthetic System is only offered as a complete system. The General Terms and Conditions of Otto Bock Healthcare apply. Date Place Signature
C-Leg - Leg prosthesis system Billing Shipping (if different from billing adress) Customer no. Order no. Orthopedic technician Com. Prosthesis user Name Age Gender male female Mobility Grade Mobility Grade 2 Mobility Grade 3 Mobility Grade 4 Weight Height Foot size kg Amputation level Knee Disarticulation Side of amputation left right bilateral Osseointegration yes no Transfemoral Hip Disarticulation/ Hemipelvectomy Ottobock 112956-EN-02-1510 Initial fitting of prosthesis (patient has never been fitted with a prosthesis before) Follow-up Fitting Prefitting with: 3C98* / 3C88* C-Leg 3C96* / 3C86* C-Leg compact 3B1 / 3B1=ST Genium 3B5-X3 / 3B5-X3=ST Genium X3 Prefitting with another knee joint Additional Component 1 Secondary Fitting 2 ( 1 Order additional components only 2 Order an additional knee joint) Manufacturer/Type/Name
C-Leg - Leg prosthesis system C-Leg (incl. AC Adapter und Battery Charger) qty. 3C98-3 C-Leg (Volcano Shadow) qty. 3C88-3 C-Leg (Volcano Shadow) for long residual limb qty. 3C98-3=9.2 C-Leg (Desert Pearl) qty. 3C88-3=9.2 C-Leg (Desert Pearl) for long residual limb Warranty 3 years 6 years Tube Adapter (minimum order quantity: 1) 2R57 Tube Adapter 2R67 Tube Adapter (torsion unit) Connection components qty. 4R57 Rotation Adapter qty. 4R57=ST Rotation Adapter with Thread qty. 4R104=60 Double Adapter, movable qty. 4R104=75 Double Adapter, movable qty. 4R72=32 Double Adapter qty. 4R72=45 Double Adapter qty. 4R72=60 Double Adapter qty. 4R72=75 Double Adapter qty. 4R76 Double Adapter qty. 4R78 Double Adapter qty. 4R40 Torsion Adapter qty. 4R118 Adapter Plate Foot parts* qty. 1D10 Men s Dynamic Foot with Toes qty. 1D11 Women s Dynamic Foot with Toes qty. 1A30 Greissinger plus qty. 1D35 Dynamic Motion qty. 1C61 Triton Vertical Shock qty. 4R43 Lamination Anchor with Threaded Connector (3-prong) qty. 4R89 Lamination Anchor with Pyramid Adapter (3-prong) qty. 4R41 Lamination Anchor with Pyramid Receiver (3-prong) qty. 4R111=N Lamination Anchor with Threaded Connector (4-prong) qty. 4R111 Lamination Anchor with Pyramid Receiver (4-prong) qty. 4R116 Lamination Anchor with Pyramid Adapter (4-prong) qty. 4R116=T Lamination Anchor, water resistant qty. 4R119 Lamination Anchor with angled arm qty. 4R119=T Lamination Anchor with angled arm, water resistant qty. 4R75=D-70 Connection Adapter with Pyramid Receiver qty. 4R170=1 Sliding Adapter qty. 4R170=2 Sliding Adapter qty. 1C62 Triton Harmony qty. 1C10 Terion qty. 1C63 Triton Low Profile qty. 1E56 Axtion qty. 1C64 Triton Heavy Duty qty. 1M10 Adjust qty. 1C40 C-Walk qty. 1C60 Triton qty. 1E57 Lo Rider qty. 1C30 Trias Color of footshell 1 beige light brown 3 Shape of footshell slim 3 normal ( 3 Not available for all foots and/or sizes. Please visit our homepage for more information.) If foot is already existing: current prosthesis foot (type, side, size) Accessories qty. 4X156 Charger Extension Cable Ankle qty. 4H105 Knee-Extender qty. 4E50-2 Battery Charger (additional) qty. 4X157 Charger Extension Cable Knee qty. 4X350 Remote Control qty. 757L16-2 AC Adapter (additional) qty. 4X158 Charger Extension Cable Ankle, long qty. 60X5 BionicLink PC qty. 4X440 C-Soft Plus Cover Protector qty. 4X860=... (S,M,L) Protector without shield insert qty. 3S26 Standard Foam Cover qty. 4P863=1 Shield Insert qty. 4P863=3 Shield Insert qty. 4P863=2 Shield Insert * Please use a seperate oder form for purchase. Regarding further information please refer to the catalogue 646K2=EN or visit www.ottobock.se C-Leg Leg prothesis system is only offered as a complete system. The General Terms and Conditions of Otto Bock Healthcare apply. Date Place Signature
Kenevo - Leg prosthesis system Billing Shipping (if different from billing adress) Customer no. Order no. Orthopedic technician Com. Prosthesis user Name Age Mobility Grade Mobility Grade 1 Mobility Grade 2 Gender male female Weight Height Foot size Side of amputation left right Osseointegration yes no kg Amputation level Knee Disarticulation Transfemoral Initial fitting of prosthesis (patient has never been fitted with a prosthesis before) Follow-up Fitting Prefitting with: Manufacturer/Type/Name Additional Component 1 Secondary Fitting 2 ( 1 Order additional components only 2 Order an additional knee joint) Ottobock 110424-EN-01-1504
Kenevo - Leg prosthesis system Kenevo (incl. AC Adapter and Inductive Charger) qty. 3C60 Kenevo qty. 3C60=ST Kenevo for long residual limb Warranty 3 years 6 years AXON Tube Adapter (minimum order quantity: 1) 2R17 AXON Tube Adapter Connection components qty. 4R57 Rotation Adapter qty. 4R57=ST Rotation Adapter with Thread qty. 4R104=60 Double Adapter, movable qty. 4R104=75 Double Adapter, movable qty. 4R72=32 Double Adapter qty. 4R72=45 Double Adapter qty. 4R72=60 Double Adapter qty. 4R72=75 Double Adapter Foot parts* qty. 1M10 Adjust qty. 1D10 Men s Dynamic Foot with Toes qty. 1D11 Women s Dynamic Foot with Toes qty. 1A30 Greissinger plus qty. 1D35 Dynamic Motion qty. 1C30 Trias qty. 1G6 Lightweight Cosmetic Foot qty. 1G9 Pedilan Single Axis Foot qty. 4R76 Double Adapter qty. 4R78 Double Adapter qty. 4R40 Torsion Adapter qty. 4R118 Adapter Plate qty. 4R119 Lamination Anchor with Pyramid Receiver and Angled Arm qty. 4R43 Lamination Anchor with Threaded Connector (3-prong) qty. 4R89 Lamination Anchor with Pyramid Adapter (3-prong) qty. 4R41 Lamination Anchor with Pyramid Receiver (3-prong) qty. 1S90 SACH Foot qty. 1H32 Single Axis Foot qty. 1S49 SACH Foot qty. 1H34 Single Axis Foot qty. 1S66 SACH Foot qty. 1H40 Single Axis Foot qty. 1S67 SACH Foot qty. 1C10 Terion qty. 1S101 SACH + Foot qty. 1S102 SACH + Foot qty. 1S103 SACH + Foot qty. 1H38 Single Axis Foot Color of footshell beige light brown 3 Shape of footshell slim 3 normal ( 3 Not available for all foots and/or sizes. Please visit our homepage for more information.) If foot is already existing: current prosthesis foot (type, side, size) Accessories Cosmesis qty. 4E70 Inductive Charger (additional) qty. 60X5 BionicLink PC qty. 757L16-2 AC Adapter (additional) qty. 4X445 K-Soft qty. 3S26 Standard Foam Cover * Please use a seperate oder form for purchase. Regarding further information please refer to the catalogue 646K2=EN or visit www.ottobock.se Kenevo Leg prothesis system is only offered as a complete system. The General Terms and Conditions of Otto Bock Healthcare GmbH apply. Date Place Signature
Cleg
www.ottobock.se Ottobock OrderformsMPK-EN-01-1510 Technical changes and printing errors reserved.