Partial Limb Prosthetic Order Form

Payment Info

CC#

Type:

Need a Casting Kit?
Yes
No

Join Our Email List?
Yes
No

Owner Information

Ship Here

Name*

Email*

Phone*

Address

Pet Information

Name*

Breed*

Fur/Hair Color

Age

Weight

Temperament

Gender
M F

Activity Level
High
Moderate
Low

Affected Limb(s):
Front Right
Front Left
R-Right
R-Left

Vet Information

Ship Here

Referring Vet Name

Vet Email

Vet Phone

Facility Address

Keep Credit Card on file?
Yes
No

Order Information

Elbow: Point of Elbow to floor, while standing, on sound side:

Hock: Point of Hock to floor, while standing, on sound side:

-Length of Stump:

Circumference of Stump:

Shipping:
Ground
2-Day
3-Day
Overnight

Brace Color:

Backup:

Select color from the following link: https://friddles.com/collections/friddles-coloring-paper
Scroll down and select colors. Some colors may be out of stock.

I have read and understand the “PATIENT AGREEMENT FORM” listed in the FAQ section of our website (www.bionicpets.org). I hereby allow Bionic Pets to charge the credit card listed above for the specified amount.

Note: After submission, you will be directed to the casting kit purchase page.

703-474-6204