Skip to content
Search for:
Home
About Us
Contact
Bone Health
Bracing & Cold Therapy
Regenerative Medicine
Prosthetics
Surgical Implants
My Account
English
French
(
Français
)
Home
About Us
Contact
Bone Health
Bracing & Cold Therapy
Regenerative Medicine
Prosthetics
Surgical Implants
My Account
English
French
(
Français
)
Search for:
Knee Brace Form
Ryan Porteous
2025-08-24T04:23:43-06:00
Custom Knee Brace Order Form
Bill To
Customer Account:
(Required)
Name
Email:
(Required)
Phone:
Your Address:
Street Address
Address Line 2
City
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code
Billing Address (If Different):
Address
City
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code
Notes/Special Instructions:
Patient Information
Patient Name:
(Required)
First
Last
Purchase Order Number: (If Applicable)
Age:
Height:
Weight:
Affected Leg:
(Required)
Left
Right
Gender:
(Required)
Male
Female
Diagnosis:
Phone:
Instability/Deficiency:
ACL
PCL
MCL/LCL
Patellofemoral
None
OA (Osteoarthritis):
Medial
Lateral
Brace Information
Brace Type:
(Required)
Fusion
Fusion Compact (Women)
Fusion XT
X2K
X2K Compact
Axiom
Axiom-D
Z12
Z12-D
Z12 OA
Z12 OA Adjustable
Duo
Thruster Legacy
Thruster RLF
20.50 Patella
Jet
Fusion
(Required)
Fusion Standard Hinge - 01209
Fusion OA Plus Medial - 01222
Fusion OA Plus Lateral - 01303
Fusion Compact
(Required)
Fusion Compact Standard Hinge - 01214
Fusion Compact OA Plus - 01225
Fusion XT
(Required)
Fusion XT Standard Hinge - 01215
Fusion XT OA Plus - 01227
Solus® Medial
(Required)
Solus Medial® OA Plus
X2K
(Required)
X2K PTO With Adj Hinge - 20025
X2K Custom With Adj Hinge - 20002
Compact X2K
(Required)
X2K Compact Standard Hinge - 20019
X2K Compact Adjustable Hinge - 20020
Duo
(Required)
Duo Short - ED312000
Duo Standard - ED112000
Thruster Legacy
(Required)
Thruster Legacy Short - TA419000
Thruster Legacy Standard - TA409000
Thruster RLF
(Required)
Thruster RLF Short - AG061016
Thruster RLF Standard - AG061012
20.50 Patella
(Required)
20.50 Standard Magnesium - AG060050
20.50 Extended Magnesium - AG060052
20.50 Standard Magnesium OA - AG060054
20.50 Extended Magnesium OA - AG060055
20.50 Standard Aluminum - AG260050
20.50 Extended Aluminum - AG260052
20.50 Standard Aluminum OA - AG260454
20.50 Extended Aluminum OA - AG260455
Axiom
(Required)
Axiom Aluminum - PK424000
Axiom Magnesium - MG424000
Axiom D
(Required)
Axiom-D Aluminum - PK428000
Axiom-D Magnesium - MG428000
Z12
(Required)
Z12 Aluminum - AZ214000
Z12 Magnesium - AZ114000
Z12 D
(Required)
Z12-D Aluminum - AZ228000
Z12-D Magnesium - AZ128000
Z12 OA
(Required)
Z12 OA Aluminum - AZ215000
Z12 OA Magnesium - AZ115000
Z12 OA Adjustable
(Required)
Z12 OA Adjustable Aluminum - AZ215000-A
Z12 OA Adjustable Magnesium - AZ115000-A
Jet
(Required)
Jet - KZ114000
Click Here If Patient Wants To See Colours -> 20.50 Colours
Click Here If Patient Wants To See Colours -> Fusion Colours
Click Here If Patient Wants To See Colours -> Axiom Colours
Click Here If Patient Wants To See Colours -> Duo Colours
Click Here If Patient Wants To See Colours -> Thruster Colours
Click Here If Patient Wants To See Colours -> Z12 Colours
Colour Examples Coming Soon
This field is hidden when viewing the form
Color Options
Jet Black
Gas Charcoal
Forest
Navy
Orange
Pink
Red
Royal
Yellow
Color Options
(Required)
Jet Black - 01
Ultramarine Blue - 11
Traffic Blue - 13
Moss Green - 17
Pure Orange - 18
Telemagenta - 19
Brown Red - 21
Traffic Red - 22
Water Blue - 23
Traffic White - 24
Reed Green - 26
Pastel Violet - 27
Slate Gray - 28
Traffic Gray Metallic - 29
Black Metallic - 33
Silver Metallic - 38
Signal Yellow - 46
Steel Blue - 51
Candy Purple - 77
Light Pink - 78
Fusion Color Options
(Required)
Charcoal (Default)
Black Metallic
Brown Red
Candy Purple
Jet Black
Light Pink
Moss Green
Pastel Violet
Pure Orange
Reed Green
Signal Yellow
Silver Metallic
Slate Gray
Steel Blue
Telemagenta
Traffic Blue
Traffic Gray Metallic
Traffic Red
Traffic White
Ultra Marine Blue
Water Blue
Color Finish Options
Gloss (Standard) Finish
Matte Finish (Only for Aluminum)
This field is hidden when viewing the form
Color Finish Options
Gloss Finish
Matte Finish
Patient Measurement
Measurements taken by:
Phone:
Offset
Offset:
Knee Width
Knee Width (in mm):
Circumference
Thigh Circumference (in inches):
Calf Circumference (in inches):
Additional Medio-Lateral Measurements for the Notes/Text Section - Those Measurements Supersede
7” above patella center
6” above patella center
6” below patella center
Additional Measurements
Bledsoe Measurement
Tibial Tool
Bledsoe Board
A1
A2
B1
B2
C1
C2
D1
D2
E1
E2
F1
F2
G1
G2
Bledsoe Circumference
7" Above KC:
3" Above KC:
3" Below KC:
6" Below KC:
Tibial Tool
1
2
3
4
5
6
Brace Accessories
Brace Accessories:
Cotton Undersleeve
Neoprene Undersleeve
Gel Condyle Pad
Oversleeve
Silicone Strap (75070)
Pad Kit (CK004012)
Suspension Sleeve
Bledsoe Brace Accessories:
High Activity Pad
Uncompress Pad Tibia
Uncompress Pad Femoral
D-Ring
PCL Straps
Cotton Undersleeve
Neoprene Undersleeve
Gel Condyle Pad
Oversleeve
Silicone Strap (75070)
Pad Kit (CK004012)
Suspension Strap (76517)
File Upload:
Drop files here or
Select files
Max. file size: 64 MB.
Are you submitting a scan via Inline Medical App?
(Required)
Yes
No
More information about the app here.
Place this order on hold:
Yes
No
By selecting this option, you confirm that this order should not be processed at this time. This is typically used when waiting on insurance approval or additional documentation. Once you are ready to proceed, please email us at orders@inlinemedical.ca with your order details to have it released and processed.
Open Inline Medical Scan
Notes/Special Instructions:
Page load link
Go to Top
