SOLID, SEMI-SOLID, PLS, & ARTICULATED AFO

You can still access the legacy PDF work order.
SOLID, SEMI-SOLID, PLS, & ARTICULATED AFO

Intake Information
Patient ID:*

First InitialLast Name
PO or Encounter #:*
Clinician Name:*
Fabrication Location:*
Other Fab location:*
Fab PCC #:*
Fab Location:
Click Here if ordering SMO, UCBL, Richie Style, Ground Reaction or DAFO Style device.
Please enter a correct Fab PCC#
Clinician Email:*
Please enter to receive confirmation.
Clinician Phone Number:*
Please enter a valid phone number.
Hospital Call/Fast Track:

Yes
Requested In-Office Date:

MonthDayYear
Date
Daily HFN Capacity
Hospital Call/Fast Track
Return Shipping Method:

GroundStandard 2 DayOvernight: PriorityOvernight: 1stLocal/Pickup
Return Shipping Method:*
Return Shipping Method:*
Shipping is same as Billing Address:*

YesNo
Bill to PCC#:*
Ship to PCC#:*
Bill to Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Ship to Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Today's Date:*

MonthDayYear
Date

SOLID, SEMI-SOLID, PLS, & ARTICULATED AFO

Device Type
Device Type*
Raven Base Code:

F1960 - AFO, THERMOPLASTIC SOLID ANKLE OR FLOOR REACTIONF1970 - ARTICULATED PLASTIC AFO
Device Type

SOLIDSEMI-SOLIDPOSTERIOR LEAF SPRINGARTICULATED W/STOPARTICULATED (FREE MOTION)ARTICULATED (POSTERIOR ENTRY)
Tuning Principles can be applied to Solid AFOs.
Unfinished:

DO NOT ARTICULATE