Metal KAFO/AFO Order Form 5.3

Metal KAFO/AFO Order Form v5.3

Standard Fabrication 7 Business Days
- Facility
- PO # (Encounter #)
- Transaction # (PCC#)
- Shipping Method
- Practitioner
- Practitioner Email
- Billing Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Shipping Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Today's Date
  
  MonthDayYear
- Requested Due Date
  
  MonthDayYear
- First Initial & Last Name
- CRM #
- Affected Side
- Sex
- Height
- Weight
- Cast Type
- Device Type
- Tracing Reversed and Device Ready for Fab?
- Set Ankle to
  
  Other
- Hindfoot Correction
  
  Other
- Forefoot Correction
  
  Other
- Heel Height
  
  Other
- Incline Tibia To (Tuning)
  
  Other
- Shoes Sent with Order?
- Degrees of Toe Out
  
  Other
- Ankle Joints
  
  Other
- Stirrup
  
  Other
- Sidebars
- Sidebars Material
  
  Other
- Sidebar Size
- Knee Joints Part #
- Knee Set in Degrees of Flexion
- Ball Retainers
- Shoe Size
- Shoe Color
- Model #
- Rocker Sole
  
  Other
- Order Status
- Thigh Section Straps
  
  Other
- AFO Section Straps
  
  Other
- Strap Material
  
  Other
- Strap Color
- Sidebars Finish
  
  Other
- Pad Straps
- Slider Material
  
  Other
- Padding Thickness
  
  Other
- Guidelines
- Additional Instructions
- If a Discrepancy Exists, Go By
- Units of Measure
- Supplemental Measurements
- Prox. Thigh Band Circumference
- Dist. Thigh Band Circumference
- Calf Band Circumference
- Prox. Thigh Band ML
- Dist. Thigh Band ML
- Knee Center ML
- Calf Band ML
- Malleoli ML
- Floor to Lateral Height
- Floor to Medial Height
- Floor to Knee Center
- Floor to Ankle Center
- Orthosis Height
- Prox. Malleoli Circumference
- Malleoli Circumference
- Proximal Malleoli ML
- Floor to Fibular Head
- Please Provide Additional Anatomical Measurements Relevant to Design
- Billing Codes
- Should be Empty:

Metal KAFO/AFO Order Form v5.3