PED Orthotics

  • Legacy forms will be accepted until Sep 1st. Access Legacy PDF work orders:

    UCB  Solid
    Low Tone SMO Articulated
    Toe Walker SMO Floor Reaction Top Entry
    SMO Floor Reaction Rear Entry
    Static Night Stretching Dynamic Night Stretching
  • 0/250

  • PED ORTHOTICS - {deviceType998}
    Intake Information

  • Please do not print the Review page.

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

  • Format: (000) 000-0000.
    • Patient Information: 
    • Bilateral:*
    • Bilateral Type:*
    • Affected Side:*

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

    • Weight Unit:
    • Submission Type:*

    • 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.

    • Device Type*
    • Raven Base Code:
    • Device Type:

  • PED ORTHOTICS - {deviceType998}
    Configurator

    • Measurements 
    • If a Discrepancy Exists, Go by:*
    • Please indicate measurement unit:*
    • Image field 347
    • Image field 861
    • Image field 892
    • Image field 867
    • Image field 866
    • Image field 886
    • Image field 887
    • Image field 868
    • Image field 888
    • Image field 745
    • Image field 815
    • Image field 816
    • Image field 839
    • Image field 841
    • Image field 843
    • Image field 846
    • Image field 863
    • Image field 893
    • Alignment 
    • Left - Ankle Alignment:*

    • Final Left Ankle Position:

    • Set the Left Ankle in   *   ° of      *        

    • Right Ankle Alignment:*

    • Final Right Ankle Position:

    • Set the Right Ankle in   *   ° of      *        

    • Left - Forefoot Alignment:*

    • Final Left Forefoot Position:

    • Set the Left Forefoot in   *   ° of      *        

    • Right - Forefoot Alignment:*

    • Final Right Forefoot Position:

    • Set the Right Forefoot in   *   ° of      *        

    • Left - Hindfoot Alignment*
    • Right - Hindfoot Alignment*
    • Modifications/Trimlines 
    • Foot Plate Modifications:*
    • Image field 1042
    • Image field 1043
    • Trimlines:*
    • Trimlines:*
    • Dorsal Wrap:*

    • Forefoot Trimline

    • Left Forefoot Trimline Container:
    • Right Forefoot Trimline Container:
    • Material/Design 
    • Plastic Type:*
    • Finished Plastic Thickness:*
    • Finished Plastic Thickness:*
    • Finished Plastic Thickness:*
    • Posterior Stop:*
    • Inner Boot options:*
    • Inner Boot options:*
    • Footplate:*
    • Other:
    • Other:
    • Plastic Color/Transfer:*

    • Special Order Transfer Papers can increase device turnaround time.

    • Stocked Transfers Container #1
    • NewLimbits Transfers Container #1
    • Friddles Transfers Container #1
    • Stocked Transfers Container #2
    • NewLimbits Transfers Container #2
    • Friddles Transfers Container #2

    • PLEASE SELECT DIFFERENT OPTIONS FOR TRANSFER PAPERS.

    • Finishing 

    • The Solid Positional AFO is a fully lined brace.

    • Crepe Post:*
    • Velcro Strap:*
    • Velcro Strap:*
    • Strap Color:*
    • Add ons 
    • Add ons:
    • Add ons:
    • Add ons:

  • PED ORTHOTICS - {deviceType998}
    Notes

  • Your order will be sent to HFN Orlando after submission.

  • Who would you like a call from?
  • 0/250
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Return Shipping Method:
  • Shipping is same as Billing Address:*
  •  - -
  •  - -
  •  - -
  •  - -
  •  - -
  •  - -
  •  - -

  • Daily HFN Capacity

  • {requestedInoffice}{requestedInoffice1172}{requestedInoffice1173}{requestedInoffice1174}{requestedInoffice1175}{requestedInoffice1176}{requestedInoffice1177}

    • Requested In-Office Date: 
    • Image field 1170

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

    •  - -
  • Should be Empty: