AFO Order Now

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:

    SCANNER

    Scanner:

    Scanner App:

    Scanned Medium:

    Email scans to scans@g9i.601.myftpupload.com

    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

    AFO Length (Floor To Proximal Edge): Length(cm)

    1: Diameter (cm)

    2: Diameter (cm)

    3: Diameter (cm)

    4: Circumference (cm)

    5: Length(cm)

    6: Length(cm)

    7: Length(cm)

    8: Length (cm)

    9: Length (cm)

    ADDITIONAL COMMENTS

    Additional Comments: