Submit Stabilizer Order Online FACILITY INFORMATION: FACILITY INFORMATION: Facility Name* Clinician Point of Contact * Due Date PO# PATIENT INFORMATION: PATIENT INFORMATION: Name * Age Gender Weight Height Diagnosis SELECT: * SELECT: * Left Right Bilateral CAST CORRECTION: * CAST CORRECTION: * Leave as is Correct to 90° Other FINISHED FOOT PLATE: FINISHED FOOT PLATE: Met. Head Sulcus Full Foot TYPE OF BRACE: (Part # 004-AP-STAB) (Reference pictures provided below) TYPE OF BRACE: (Part # 004-AP-STAB) (Reference pictures provided below) Ankle Stabilizer I Ankle Stabilizer II TYPE OF HINGE: TYPE OF HINGE: Free Motion (See Picture Below) Restricted (See Picture Below) Free Motion (Tamarack) Dorsi-Assist (Tamarack) If Other, provide more details. ADD ONS: ADD ONS: Design (Part # 012-AP-TFR) Transfer Paper # Special Instructions: Special Instructions: Submit Order Reference Pictures: Please use the following images as references. Provide the details in the “Type of Brace” and “Type of Hinge” form section above.
