Metal KAFO/AFO Order Form 5.2

Metal KAFO/AFO Order Form v5.2

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

City State / Province

Postal / Zip Code Country
Shipping Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Order Information
Today's Date

Month Day Year
Requested Due Date *

Month Day Year
First Initial & Last Name *
CRM #
Affected Side *
Sex
Height
Weight

Additional Instructions
Guidelines

Return Cast Trimlines Drawn on Cast Trimlines Provided as a Sketch
Additional Instructions

Anatomical Measurements
If a Discrepancy Exists, Go By *

Impression Measurements
Units of Measure *

Centimeters Millimeters
Supplemental Measurements

Yes No
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