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AFO Order Form

GENERAL

Clinic/Hospital Name:

Provider Name:

Shipping Address:

City:

State:

Zip Code:

Phone Number:

Billing Point of Contact:

Billing Contact Email:

PO#:(optional)

Email:

Please check the box if billing address is same as shipping address.

Billing Address:

City:

State:

Zip Code:

PATIENT

First Name:

Last Name:

Birthday:

Weight (lbs):

Height (in):

Gender: MaleFemale

Foot Side: LeftRightBilateral

Lead Time

Lead Time:

OPTIONS

AFO Type:

Cast Corrections:

Heel Posting:

Heel Posting Material:

Encompassing:

Ankle Strapping:

Ankle Strapping Material:

Ankle Strap Position:

Calf Strapping:

Calf Strapping Material:

Materials:

ProFlex Inner Boot (1/8"):

Joints:

Graphic Lamination:

Foot Plate Length:

Insole:

Additions

Posterior Stop:

Padding:

Volara Padding Thickness:

Ankle Reinforcement:

Heel Cut Out:

All Dacron Strap:

Measurments

Measurement 1:

Diameter (cm)

Measurement 2:

Diameter (cm)

Measurement 3:

Diameter (cm)

Measurement 4:

Circumference (cm)

Measurement 5:

Length(cm)

Measurement 6:

Length(cm)

Measurement 7:

Length(cm)

Measurement 8:

Length (cm)

Measurement 9:

Length (cm)

ADDITIONAL COMMENTS

Additional Comments: