PED Orthotics

PED ORTHOTICS - {deviceType998}
Intake Information

Please do not print the Review page.

Scroll to the bottom, hit Complete and then download the work order.

Please enter to receive confirmation.

Please enter a valid phone number.Format: (000) 000-0000.

Symmetrical (Same Work order)Asymmetrical (Separate Work orders for each side)

Build by Measurement (No cast required) available for patients under 81 lbs/37 kg.

Physical CastBy Measurement Only

Submission Type:

Plaster Cast: Negative or Positive

Please include a printed Work Order with the cast when shipping.

Your order will be sent to HFN Orlando after submission.

The Shipping section is now at the end of the form.

PED ORTHOTICS - {deviceType998}
Configurator

ImpressionMeasurements

Decimal value optional

As CastedSet in NeutralOther

Final Left Ankle Position:

Set the Left Ankle in Degrees* ° of Dorsiflexion Plantarflexion*

As CastedSet in NeutralOther

Final Right Ankle Position:

Set the Right Ankle in Degrees* ° of Dorsiflexion Plantarflexion*

As CastedSet in NeutralOther

Final Left Forefoot Position:

Set the Left Forefoot in Degrees* ° of Varus Valgus*

As CastedSet in NeutralOther

Final Right Forefoot Position:

Set the Right Forefoot in Degrees* ° of Varus Valgus*

As CastedSet in Neutral

PLSPLS with Posterior Reinforcement

STD-NO EXTEXT BOTHLATERAL EXTMEDIAL EXT

PolypropyleneCopolymerModified Polyethylene

Modified Polyethylene

3/32" (2 mm)1/8" (3 mm)Other

3/32" (2 mm)1/8" (3 mm)5/32" (4 mm)Other

1/16" (1.5 mm) STANDARD3/32" (2 mm)

3/32" (2 mm) LDPE3/32" (2 mm) Optiflex1/8" (3 mm) Foam

None3/32" (2 mm) LDPE3/32" (2 mm) Optiflex1/8" (3 mm) Foam

Standard (Extended Lateral)Met Head LengthFull Foot Length

Standard (Full Foot Length)

Plastic Heel PostInner Boot

White PlasticBlack PlasticStocked Transfer PaperSpecial Order Transfer Paper

Special Order Transfer Paper

PLEASE SELECT DIFFERENT OPTIONS FOR TRANSFER PAPERS.

FinishedLeave UnattachedNone

Non Skid SurfaceStrap pad (Slider)Additional pair of Dorsal ChipsAdditional pair of Socks

Non Skid SurfaceAdditional pair of Dorsal ChipsAdditional pair of SocksShoes

PED ORTHOTICS - {deviceType998}
Notes

Your order will be sent to HFN Orlando after submission.

Modifications (Modifier)Design options on device (Fab Supervisor)Shipping/Billing (Customer Support)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Order ship date may be impacted by incomplete order, component availability and upon cast receipt (for physical orders).

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Clinicians can still coordinate special in-office requests by emailing:
HFN_Hypercare@hanger.com

Date

Hour MinutesAM/PM Option

UCB	Solid
Low Tone SMO	Articulated
Toe Walker SMO	Floor Reaction Top Entry
SMO	Floor Reaction Rear Entry
Static Night Stretching	Dynamic Night Stretching

Forefoot Trimline

Special Order Transfer Papers can increase device turnaround time.

The Solid Positional AFO is a fully lined brace.