ANKLE FOOT ORTHOSIS ORDER FORM
If you need any assistance, email success@protosthetics.com or call us at (701)-478-2001
Practitioner Name
*
First Name
Last Name
Practitioner Email
*
example@example.com
PO#
*
Need By
-
Month
-
Day
Year
Date
Facility
*
Shipping Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DELIVERY METHOD
*
Please Select
Ground
2-day (additional charges)
Overnight (additional charges)
Local Pickup
Galileo — Print In Clinic
PATIENT INFORMATION
Diagnosis/Special Instructions
Have a Tech Call Me
Yes
Side
*
Left
Right
Fabrication Instructions
AFO Type
Please Select
—
Solid Ankle
Articulated
Unloaded
Semi-Solid Ankle
Split Upright
Posterior Leaf Spring
Cast Corrections
Please Select
—
Leave as Casted/Scanned
Correct to 90
Other
Other Cast Corrections
Material
*
Please Select
—
Co-Poly
Poly Pro
Material Color
*
Please Select
—
Natural
Black
Material Thickness
*
Please Select
—
1/8"
3/16"
Graphic Lamination
(specify pattern from www.newlimbits.com)
Heel Posting
*
Please Select
None
Intrinsic
Extrinsic
Posting Direction
Please Select
—
Varus
Valgus
Angle
Encompassing
*
Please Select
None
1st Met
5th Met
Calf Strapping Type
Please Select
—
Standard w/ Chafe
Layover
Wrap Around
Calf Strapping Color
Black
White
Calf Strapping Width
Please Select
—
1"
1.5"
2"
Ankle Strapping
Yes
Ankle Strapping Type
Please Select
—
Standard w/ Chafe
Layover
Wrap Around
Banjo Strap
Ankle Strap Width
Please Select
—
1"
1.5"
2"
Ankle Strap Color
Black
White
Ankle Strap Position (if applicable)
Please Select
—
Varus
Valgus
Joints
Please Select
—
Free Motion Tamarack
Dorsi-Assist Tamarack
Overlap
Oklahoma
Foot Plate Length
Please Select
Full (standard)
Sulcus
3/4
Insole
Yes
Insole Length
Please Select
—
Full
Sulcus
3/4
Insole Material
Please Select
—
P-Cell
EVA
NeoSponge
NeoSponge w/ X-Static (Additional Charge)
Insole Thickness
Please Select
—
1/8"
3/16"
ADDITIONS
1/8” Proflex Inner Boot
Please Select
—
Full
Foot
Posterior Stop
Please Select
—
90 degree
Adjustable
Volara Padding
Yes
Volara Padding Area
Please Select
—
Forefoot
Entire Device
Spot
Volara Padding Type
Please Select
—
Black 3/16"
Black 1/4"
White 3/16"
White 1/4"
Volara Padding Spot
Ankle Reinforcement
Please Select
—
Plastic Strut
0.06" Carbon Strut
0.09" Carbon Strut
Heel Cut Out
Yes
All Dacron Stop
Yes
Circumference at Trim
Malleoli Circumference
M-L at Malleoli
Lateral Malleolus Height
Trim Height
Medial Malleolus Height
M-L at Mets
Mets Circumference
Additional Information
Note: Protosthetics can only make products as well as you describe your needs - please be thorough!
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