AFO Order Form
v 2.2
Order Information
Today's Date
.
Month
.
Day
Year
Date Picker Icon
Requested Due Date
*
.
Month
.
Day
Year
Date Picker Icon
PO #
*
Affected side
*
Please Select
Left
Right
Bilateral
Gender
*
Please Select
M
F
Full Name
*
Patient ID
Activity Level
Please Select
Low (K1)
Moderate (K2)
Average (K3)
High (K4)
Height
*
Weight
*
Age
*
Account Information
Account #
Practitioner
*
Facility
*
Shipping Method
Please Select
Courier
Ground
2 Day
Next Day Saver
Next Day Air
Bill to:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Ship to:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Same as billing address
1. Device
Type:
*
Flex
Semi-Rigid
MJ Semi-Rigid
Rigid
Solid
Articulated
Pre-Articulated
NT Splint
Articulated Night Splint
Tuned AFO
Other
Set Ankle at:
*
As Is
90'
5'PF
90' with heel height accommodated for.
Other
Incline TIbia to (Tuning):
90'
Other
Heel Height
1/4"
3/8"
1/2"
Other
Cast
Please Select
Negative
Modified
CAD
Device: Additional Instructions
2. Design
Modification
*
Minimal
Standard
Tone Reduction
Club Foot
Other
Foot Plate
*
Full
Sulcus
Metatarsal
NYU/UCB
Anterior Shell
None
Unlined
Lined
Tongue
Anterior Shell design
Sliding
Overlap
Shell Material
Lining Thickness
Tongue Thickness
Proximal Flare
Yes
No
Dorsal Flaps
Yes
No
Additional Instructions
Dorsal Flap Design
Doral Flap Strap
*
Dacron Backed
Leather Backed
Hook & Loop Only
No Straps
Ankle Joints
*
Tamarack
Oklahoma
Gillette
Gafney
Double Action
None
Other
Dorsi Assist
75 (Mild)
85 (Moderate)
95 (High)
Planter Stop
*
Adj Planter Stop
Otto Bock Snapstop
Planter Stop
None, Free Motion
Other
Heel Flare
Yes
No
Heel Flare
Lateral
Medial
Full
None
Heel Flare Material
Crepe
Molded
None
Heel Height Posting
Forefoot Trim
Standard
Extend lateral
Extend medial
Extend both
Extend lateral (just past met heads and relieved)
Extend medial(just past met heads and relieved)
Extend both(just past met heads and relieved)
Other
Valgus/Varus Control
Lateral
Medial
Padded before Pull
Padded After Pull
Valgus/Varus Control (Left Side)
Lateral
Medial
Padded before Pull
Padded After Pull
Valgus/Varus Control (Right Side)
Lateral
Medial
Padded before Pull
Padded After Pull
Valgus/Varus Padding
3/16 White Pelite
Other
Padding
Full Device
Naviculars
Lat Malleolus only
Malleoli
Med Malleolus only
Heel
Full Foot
1 pc Malleoli/Cal/Nav
Calcaneus
Other
When to Pad:
Before Pull
After Pull
After Pull with Dummies
N/A
Padding Material
Aliplast
Plastizoate
Puff
Other
Padding Thickness
1/8
3/16
1/4
Other
Pad Color
White
Blue
Other
Design: Additional Instructions
3. Thermforming
Plastic
*
PolyPro
CoPoly
Modified PolyEthylene
Other
Thickness
*
3/32
1/8
5/32
3/16
1/4
Other
Color
*
Please Select
White
Flesh
Black
Brown
Hispanic
Dark Blue
Pink
Purple
Red
Full Transfer
Transfer Description
Thermoforming: Additional Instructions
4. Finishing
Straps
*
Calf
Wrap Around
Instep
Internally Mounted Instep Strap
Dorsal Flap
Toe
Dorsi Pull Straps
Leave Straps unattached
Mount Straps Internally
Other
Slot Location
Medial
Lateral
N/A
Strap Material
*
Leather
Dacron
Other
Strap Color
*
Pearl
White
Black
Brown
Flesh
Other
Pad Straps
*
None
Aliplast Stitched
Sliders
Other
Slider Material
*
Aliplast
Felt
Other
Padding Thickness
1/8
3/16
1/4
Aliplast Thickness
1/8
Rivets
Speedy
Copper
Non Skid Surface
Yes
No
Non Skid Surface (Topi)
Met Head / Heel
Full
Non Skid Surface Color
White
Black
Tan
Finishing: Additional Instructions
5. Additional Instructions
Guidelines
Return Cast
Trimlines drawn on cast
Trimlines provided as a sketch
6. Anatomical Measurements
If a discrepancy exists go by :
*
Impression
Measurements
Hind Foot Correction(Position of finished device)
*
Neutral
As Is
Other
Ankle Ridgity
Flexible
Rigid
Rotation of Leg
Toe In
Toe Out
Degrees of Rotation
Forefoot Correction
*
Neutral
As Is
Other
Units of Measure
*
Inches
Centimeters
Calf Circumference
Calf ML
Ox Height
*
Ankle Center Height
ML just above Malleoli
ML @ Malleoli
Metatarsal ML
*
Length of Patient's Foot
Medial Foot Plate Length
Lateral Foot Plate Length
Anatomical: Additional Info
If you would like a PDF Report of your order, please provide your email address below.
Practitioner Email
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