Submit Leather AFO Order Online

FACILITY INFORMATION: FACILITY INFORMATION:

Facility Name *

Clinician Point of Contact *

Due Date

PO#

PATIENT INFOMRATION: PATIENT INFOMRATION:

Name *

Age

Gender

Weight

Height

Diagnosis

SELECT: * SELECT: * Left Right Bilateral

CAST CORRECTION: * CAST CORRECTION: * Leave as is Correct to 90° Other

If Other, provide more details.

STYLE OPTIONS: * STYLE OPTIONS: * Standard (Part # 005-AP-LAFO) 5"above Malleoli High Profile (Part # 006-AP-HPLAFO) 9" above Malleoli (Part # 006-AP- HPLAFO) EX-tend Articulated Other (Part # 006-AP-HPLAFO)

FINISHED FOOT PLATE: * FINISHED FOOT PLATE: * Met. Head Sulcus Full Foot

COLOR * COLOR * Black White Brown Sand Pink

CLOSURE: (Choose multiple for combo) * CLOSURE: (Choose multiple for combo) * All Straps One Strap Two Straps Eyelets (Laces) Speed laces (Ski Hooks) Boot Hooks

ADD ONs: (Extra Fees May Apply) ADD ONs: (Extra Fees May Apply)

JOINT SELECTION: (Part # 009-AP-JOINT) JOINT SELECTION: (Part # 009-AP-JOINT) Free Motion (Tamarack) Dorsi-Assist (Tamarack) Other

STOP: STOP: Simple 755-MCL PAS-100-A None

Special Instructions: Special Instructions: