Order Form AFO - DOC

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					                      NATIONAL LAB LOCATIONS (Choose One)

                        Orlando:
                        Kansas:
                                    Ph 407.852.6170
                                    Ph 913.888.4200
                                                      |
                                                      |
                                                          Fx 407.852.6171
                                                          Fx 913.888.4244
                                                                            Workorder #                                   Page 1 of 2
                        Tempe:      Ph 480.894.1755   |   Fx 480.921.9686
                        Anaheim:    Ph 714.961.2155   |   Fx 714.961.2181
                        CDC:        Ph 480.377.2226   |   Fx 480.377.2896    (FOR LAB USE ONLY)



Bill To:                                                                      Patient Name:
Address:
                                                                              Height:                        Left          Male
                                                                              Weight:                        Right         Female
Ship To:                                                                        Age:                         Bilateral
Address:

                                                                              OPS Patient ID:
Practitioner:
Phone #:                                                                      In-Office Request Date:                            am     pm


      STANDARD METAL                                                               Pad STS                       Post Rear Foot or
      Standard Metal AFO Includes:                                               Type:                           Fore Foot Crepe/Cork
      ● Metal Calf Band                                                            Pad Arch                      Post Full Foot Crepe/
      ● Leather Cuff                                                             Type:                           Cork
      ● Stirrup Attached to Shoe                                                   Pad Toe Ramp                  Post Rear Foot or
                                                                                 Type:                           Fore Foot Polypro
      STANDARD PLASTIC                                                             Dacron Reinforced             Vent Holes
      Standard Plastic AFO Includes:                                               to Strap (each)               Carbon
      ● 5/32 Finished Polypro                                                      Leather Reinforced            Reinforcements
      ● Ankle set at 90 degrees                                                    to Strap (each)               Bars Under Plastic
      ● Velcro closures                                                            Pre Tib Strap                 Decal Application
                                                                                   De-rotation Strap            Type:
      STANDARD ARTICULATED                                                         Instep Strap                  Tibial Torsion
      Standard Articulated AFO Includes:                                           Figure 8 Strap                Patten Bottom
      ● 5/32 Finished Polypro                                                      Strap Pad                     Caliper
      ● Becker 740 Tamarack Joints                                                 Tone Reducing Feature         Split Stirrup
      ● Velcro closures                                                            PTB Feature                   Long Tongue Stirrup
                                                                                   Plastic UCB                   Metal Foot Plate/
      STANDARD PEDIATRIC TONE                                                      Plastic Inner Boot 1/16       Stirrup
      REDUCING                                                                     Material                      Growth Extension
      Standard Pediatric Tone Reducing AFO Includes:                             Type:                           Calf/Thigh Band
      ● 1/16 Finished Polypro                                                      Add Plastic Tib Shell         Spreader Bar
      ● Two (2) Straps                                                             Plastic Tongue 1/16
                                                                                   Material

                 NON-STANDARD OPTIONS                                                               LEATHER OPTIONS
                                                                                   Molded Calf Corset           Calf Cuff 180
     Cast Modification                   Metal Double Upright                          Laces       Velcro       T-Strap
     Plastic Pull Only                   Metal Single Upright                      Full Calf Corset Non         Patella Strap
     Solid Ankle                                                                   Molded                       T-Strap Custom to
     Plastic Articulated Ankle                                                         Laces       Velcro       Tracing
     Plastic Double Upright                                                        Calf Cuff 360
     Plastic Floor Reaction
     DAFO                                                                                           TYPE OF PLASTIC
     SMO                                                                           Natural Polypro            Color
                                                                                   Natural Copoly             Finished
     Liner Full AFO                      Pad Malleolus                             Natural Polyethylene       Thickness
   Type:                               Type:                                       Other                          1/8     3/16        1/4

AFO v6p1 [www]                                                                                                                    DA 03/10/2011
Page 2 of
        2
  PATIENT NAME:                                                                               BRANCH:

                   LINER                              CORRECT ANKLE TO                                      TYPES OF ANKLE JOINTS
                                                                                                Gaffney Ankle Joint
  Thickness                                             90 degrees                              Gillette Ankle Joint
                                                        Other                                   Oklahoma Ankle Joint
  Density                                                                                       Tamarack
                                                                                                Tamarack Dorsi-Assist
  Color                                                                                         Free Motion Ankle
                                                                                                Limited Motion Ankle
                                                                                                Klenzak Ankle
                     M-L at Knee                                                                Double Action Ankle
                                                                           K.C.                 Other

                                                                                                                  ANKLE STOP
                                                                           F.H.                 Elite PAS-100 (Posterior Adj. Stop)
                                                                                                Elite PAS-100 (Posterior Spring Assist)
   AFO Height
                                                                                                655-MCL (Motion Control Limiter)
                                                                                                755-MCL (Motion Control Limiter)
                                                                            Calf
                                                                                                795-MCL (Motion Control Limiter)
                                                                                                Other
                        M-L at Calf
                                                                          Mid Calf
                       Fib head
                        to floor                                                                                                                        Trim To:
         MPT to                                                                                                                                            Solid Ankle
          floor                                                          Above A                                                                           Semi Solid
                                                                                                                                                           Posterior
                                                                                                                                                           Leaf Spring
                                                                                                Anterior trim
                                                                           Ankle
                                 M-L at Ankle                                                     to floor



                                                                                                                                                         Posterior trim
                                                                                                                                                            to floor
     Heel to       Heel to toe                              Distal tip of Degree of toe
     Sulcus                                                   medial          out
                                                            malleolus to
                                                                floor
                                      Width at Met. Heads




  SPECIAL INSTRUCTIONS:




                                                                                                NATIONAL LAB LOCATIONS (Choose One)


     Page 2 of 2                                                       Workorder #                Orlando:
                                                                                                  Kansas:
                                                                                                                Ph 407.852.6170
                                                                                                                Ph 913.888.4200
                                                                                                                                  |
                                                                                                                                  |
                                                                                                                                      Fx 407.852.6171
                                                                                                                                      Fx 913.888.4244
                                                                                                  Tempe:        Ph 480.894.1755   |   Fx 480.921.9686
                                                                                                  Anaheim:      Ph 714.961.2155   |   Fx 714.961.2181
                                                                                                  CDC:          Ph 480.377.2226   |   Fx 480.377.2896
                                                                         (FOR LAB USE ONLY)
  AFO v6p2 [www]                                                                                                                                                 DA 03/10/2011

				
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