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CUSTOM ALSO
ORDER FORM
Customer ID:Order Date:Date Needed:PO#:BILLING INFORMATION
Facility:Contact Name:Address:City:State:Zip:Phone:Fax:Email:SHIPPING Informational as BillingFacility:Contact:Cell
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How to fill out custom tlso order form
How to fill out custom tlso order form
01
Begin by gathering all the necessary information for filling out the custom tlso order form.
02
Ensure you have the patient's personal information, including their name, contact information, and date of birth.
03
Specify the measurements required for the tlso order, such as the patient's waist circumference, chest circumference, and height.
04
Indicate any additional customizations or modifications needed for the tlso, such as specific padding or strap adjustments.
05
Provide the ordering physician's details, including their name, contact information, and any specific instructions they may have.
06
Double-check all the filled-out information to ensure accuracy and completeness.
07
Once the form is complete, submit it to the appropriate department or supplier to process the custom tlso order.
Who needs custom tlso order form?
01
Any individual who requires a custom tlso (thoracolumbosacral orthosis) would need to fill out a custom tlso order form.
02
This can include patients with spinal conditions, injuries, or postoperative needs that require immobilization or support in the thoracic, lumbar, or sacral regions.
03
Healthcare professionals, such as orthotists or physicians, may also need to fill out this form when ordering custom tlso devices for their patients.
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What is custom tlso order form?
Custom tlso order form is a document used to request a custom made Thoraco-lumbo-sacral orthosis (TLSO) brace for a patient.
Who is required to file custom tlso order form?
Healthcare providers such as physicians, orthotists, or physical therapists are required to file custom tlso order form.
How to fill out custom tlso order form?
Custom tlso order form must be filled out with patient information, brace specifications, and healthcare provider details.
What is the purpose of custom tlso order form?
The purpose of custom tlso order form is to document the need for a custom TLSO brace and provide instructions for its fabrication.
What information must be reported on custom tlso order form?
Custom tlso order form must include patient's name, diagnosis, brace measurements, healthcare provider's signature, and date.
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