Submit AFO 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 If Other, provide more details. STYLE OPTIONS: * STYLE OPTIONS: * Solid (Part # 001-AP-AFO) Articulated (Part # 002-AP-ARTAFO) Floor-Reaction Semi-rigid Posterior Leaf Spring FINISHED FOOT PLATE: * FINISHED FOOT PLATE: * Met. Head Sulcus Full Foot MATERIAL OPTIONS: MATERIAL OPTIONS: Plastic: * Plastic: * Polypropylene Copolymer 3/16 1/4 Other If Other, provide more details. Color: Color: Natural Black Design (Part # 012-AP-TFR) Transfer Paper # Foam Liner: Foam Liner: Lined (Part # 010-AP-LINER) Unlined 1/8 3/16 1/4 Other If Other, provide more details. ADD ONs: (Extra Fees My Apply) ADD ONs: (Extra Fees My Apply) STOP: STOP: Simple (Part # 019-AP-SSTOP) 755-MCL (Part # 018-AP-STOP) PAS-100-A None (Part # 018-AP-STOP) JOINT SELECTION: (Part # 009-AP-JOINT) JOINT SELECTION: (Part # 009-AP-JOINT) Free Motion (Tamarack) Dorsi-Assist (Tamarack) Other CLOSURE: * CLOSURE: * Calf Dorsum Strap Ankle POSTINGS: (Part # 011-AP-POST) POSTINGS: (Part # 011-AP-POST) Heel: Heel: Medial Lateral Full Material: Material: Plastic Crepe Forefoot: Forefoot: Medial Lateral Material: Material: Plastic Crepe OTHER: OTHER: Carbon Reinforcement (Part # 008-AP-CARBON) Insole Insert (Part # 016-AP-EXTRA) MEASUREMENTS: (Reference picture provided below) * MEASUREMENTS: (Reference picture provided below) * Widest Calf Above Ankle Ankle Met. Head Floor to Knee Foot Plate Length Special Instructions: Special Instructions: Submit Order Reference Picture: Please use the following image as a reference. Provide the details in the “Measurements” section above.
