Metal KAFO/AFO Order Form 5.3

Metal KAFO/AFO Order Form v5.3

Standard Fabrication 7 Business Days

Account Information
Facility*
PO # (Encounter #)*
Transaction # (PCC#)
Shipping Method*
Practitioner*
Practitioner Email*
Same Billing/Shipping Address
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

Order Information
Today's Date

MonthDayYear
Requested Due Date*

MonthDayYear
First Initial & Last Name*
CRM #
Affected Side*
Sex
Height
Weight

Additional Instructions
Guidelines

Return CastTrimlines Drawn on CastTrimlines Provided as a Sketch
Additional Instructions

Anatomical Measurements
If a Discrepancy Exists, Go By*

ImpressionMeasurements
Units of Measure*

CentimetersMillimeters
Supplemental Measurements

YesNo
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