Lower Extremity Prosthetic Fabrication

Thermoplastic AFO Fabrication
AFO
Patient Name:*

First InitialLast Name
PO #:*
Practitioner:*
Clinic Location:*
Email*
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Today's Date:*

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Date
Due Date:

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Date

Thermoplastic AFO Fabrication

Patient Information
Affected Side:*

LeftRight
Diagnosis:*
Weight:*
Age*

Thermoplastic AFO Fabrication

Measurements
Build from mold (measurements not required):*

YesNo (correct mold to measurements provided, then modify)
Left - Measurements:
Right - Measurements:
Left - Trim Height:*
Right - Trim Height:*

Thermoplastic AFO Fabrication

Notes
I would like a phone call to discuss this project prior to starting fabrication

Yes
Notes:

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