SOLID, SEMI-SOLID, PLS, & ARTICULATED AFO
  • Access Legacy PDF work order. Legacy form will be accepted until Aug 15th. 

  • Please do not print the Review page.

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

  • SOLID, SEMI-SOLID, PLS, & ARTICULATED AFO

    Intake Information
  • Please enter a correct Fab PCC#

  • HFN Rocky Hill (Cromwell) has relocated! Our new address is:
    31 Inwood Rd, Rocky Hill, CT 06067

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

      • Left and Right sides can have different Measurements
      • Same Alignment, Design and Finishing options
    • Please use the Special Order Pediatric form for Non-Standard Pediatric Designs. This form cannot be used for patients under 18.

    • Weight Unit:
    • Scan being submitted with order: (Deprecated-Do Not Delete)*
    • Submission Type:*
    • Scanner Type:*
    • Upload Scan at the end. 

    • Hanger 3D app:*
    • Submission Type:

      • Plaster Cast: Negative or Positive

        Please include a printed Work Order with the cast when shipping.
    • Your order will be sent to CDC after submission. 

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    • Is this a Hanger3D app scan?*
      • Please complete this form. Next, after acquiring the scan via the Hanger3D app, go to Order Forms > Jotform Order and fill out the required information and submit the scan. NO OTHER ACTION IS NEEDED

        

    • Scan Type:*
    • The Cast Measurement fields are available at the end of the Form. 

    • Due to the scan being modified, the Alignment and Modification options will not be displayed.

      Any Alignment or Modification changes can be called out in the Notes section. 

    • Since the Positive plaster model is already modified, the Alignment and Modification options will not be displayed.

      Any Alignment or Modification changes can be called out in the Notes section. 

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

  • SOLID, SEMI-SOLID, PLS, & ARTICULATED AFO

    Device Type
  • Raven Base Code:
  • Device Type:
  • Tuning Principles can be applied to Solid/Semi-Solid AFOs. 

  • SOLID, SEMI-SOLID, PLS, & ARTICULATED AFO

    Configurator
  • 0/250
    • Tuning: 
    • Tuning: Is this device being tuned?*
    • Casting block Height and Toe Ramp Angle measurements are recommended.
      If Heel Wedging alone is required, please proceed to the Materials/Design Section.

    • Foot on Casting block
    • Please indicate measurement unit:*
    • Tuning Type:*
    • Image field 1385
    • Image field 1386
    • Tuning Ankle Alignment:*
    • Image field 1388
    • Final Ankle Position (Ankle Angle):

    • Set the Ankle in   *   ° of      *       

    • Image field 1389
    • Toe Ramp:*
    • Image field 1316
    • Image field 1317
    • Image field 1318
    • Image field 1392
    • Set Heel Wedge/Post To:*
    • Set Heel Wedge/Post To:*
    • Image field 874
    • Image field 1394
    • Image field 1395
    • Shoe Heel Height:*
    • Posting Type:*
    • Image field 1321
    • Image field 1322
    • Image field 1324
    • External Post Attachment:*
    • Measurements: 
    • Submissions with Scans require measurements. Go By Impression will be disabled. 

    • Go by:*
    • Please indicate measurement unit:*
    • Patient Measurements
    • Patient Measurements
    • Selected unit: {pleaseIndicate910}

    • Alignment: 
    • Toe Ramp Container - Posting Section:
    • i

      NEUTRAL is the Tibia perpendicular to the floor based on Heel Height. 

    • Ankle Alignment:*
    • Final Ankle Position:

    • Set the Ankle in   *   ° of      *        

    • Shoe Heel Height Accommodation:*
    • Forefoot Alignment:*
    • If "As Casted" Forefoot Alignment is required, please select "Other" and provided the as casted alignment. 

    • Final Forefoot Position:

    • Set the Forefoot in   *   ° of      *        

    • Hindfoot Alignment:*
    • Final Hindfoot Position:

    • Set the Hindfoot in   *   ° of      *        

    • Modifications/Trimlines: 
    • Tone Reducing Modifications:
    • Image field 1232
    • Image field 1233
    • Buildups/Reductions:
    • Standard Mods include:

      • 1/8" (3 mm) buildup at the Malleoli, Navicular and Base of the 5th. 
      • 1/8" (3 mm) reduction at the Medial Longitudinal Arch Apex. 
    • Met Heads:
    • Medial Malleolus:
    • Lateral Malleolus:
    • Navicular:
    • Base of the 5th:
    • Posterior Heel (pump bump):
    • Medial Longitudinal Arch Apex Reduction:
    • Image field 1047
    • Image field 1048
    • Foot Mod Add ons:
    • Intrinsic Heel Skive:*
    • Skive Magnitude:*
    • Intrinsic Heel Skive requires external posting/wedging.

    • i

      Standard Default: 1/8" deflection at Malleoli away from the leg to reduce edge pressure

    • Trimline Profile:*
    • Image field 1185
    • Image field 1186
      • Standard: 1/8" deflection from the leg with extra accommodation at the malleoli to reduce edge pressure.
      • Gutter: Material added to create a "gutter" shape so the trimlines are inline with the apex of the buildups. (Commonly used for Positioning or Night time Stretching AFOs).
    • Trimline Profile Default
    • Trimline Profile:
    • Trimline Profile Location Default
    • Gutter Trimline Profile Location:*
    • Image field 1189
    • Image field 1190
    • Image field 1191
    • Midfoot Trimline Default:
    • Midfoot Trimline:
    • Image field 1106
    • Plastic Footplate Trimline Default:
    • Provided Finished Foot Plate Length: {finishedPlastic1000}{finishedPlastic999}

    • Footplate Trimline:
    • Forefoot Trimline Default:
    • Forefoot Trimline:
    • Image field 1049
    • Image field 1064
    • Additional Options:
    • Image field 1050
    • Left Supramalleolar Extension:*
    • Right - Supramalleolar Extension:*
    • Materials/Design: 
    • Shoe Heel Height Container (Alignment section):
    • {intrinsicHeel990} Intrinsic Heel Skive was selected.

    • Posting:

    • Posting Type:*
    • Image field 1326
    • Image field 1327
    • Image field 1328
    • Image field 1329
    • Posting Location:*
    • Image field 1332
    • Image field 1333
    • Image field 1334
    • Image field 1335
    • Image field 1336
    • Image field 1337
    • Image field 1338
    • Heel Post Amount:
    • External Heel Wedge:
    • Material:*
    • Toe Ramp:*
    • Image field 1344
    • Image field 1345
    • Image field 1118
    • Posting options will not be available if a Heel Wedge is selected.

    • Heel Post - DEPRECATED - DO NOT DELETE:
    • Heel Post Material:*
    • Image field 1119
    • Image field 1120
    • Image field 1121
    • External Forefoot Post:
    • External Forefoot Post Material:*
    • Image field 1122
    • Image field 1123
    • Image field 1138
    • Ankle Joints

    • Joints:*
    • Tamarack w/Dorsiflexion Assist:*
    • Posterior Stop:*
    • Image field 1299
    • Image field 1294
    • Image field 1295
    • Image field 1296
    • Image field 1297
    • Plastic

    • i

      Finished Plastic Thickness will be within 10% of the requested thickness. 

    • Plastic Type:*
    • Finished Plastic Thickness:*
    • Finished Plastic Thickness:*
    • 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.

    • Reinforcement:
    • Inner Boot:
    • Inner Boot Thickness:*
    • Inner Boot Thickness:*
    • Image field 1082
    • Padding: 
    • Full Device Padding Thickness:*
    • Supramalleolar Ext. Padding Thickness:*
    • Plantar Surface Padding Thickness:*
    • Additional Padding

    • Malleoli Padding:
    • Malleoli Padding Thickness:*
    • Calf Padding Thickness:*
    • Navicular Padding Thickness:*
    • Additional Padding Insertion:
    • Finishing: 
    • Fastener Type:*
    • Strap Type:*
    • Leather Strap Color:*
    • Dacron Strap Color:*
    • Velcro Strap Color:*
    • Calf Strap Width:
    • Calf Strap Placement:*
    • Proximal Ankle Strap Width:
    • Proximal Ankle Strap Placement:*
    • Instep Strap Width:
    • Instep Strap Placement:*
    • Instep Strap Style:*
    • Image field 1065
    • Image field 1069
    • Image field 1142
    • Add-Ons:
    • Non-Skid Surface:*
  • SOLID, SEMI-SOLID, PLS, & ARTICULATED AFO

    Notes
  • Your order will be sent to CDC after submission along with the Scan. No futher action is needed.

    (No Entry required at the LEO portal)

  • Your order will be sent to CDC after submission. No futher action is needed.

    (No Entry required at the LEO portal)

    • Please complete this form. Next, after acquiring the scan via the Hanger3D app, go to Order Forms > Jotform Order and fill out the required information and submit the scan. NO OTHER ACTION IS NEEDED

      

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  • Patient Gender:*
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  • 0/250
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  • Return Shipping Method:
  • Shipping is same as Billing Address:*
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  • Daily HFN Capacity

  • This option is for requests requiring a 24–48 hour turnaround. An expedite fee might apply.

  • {requestedInoffice}{requestedInoffice1362}{requestedInoffice1363}{requestedInoffice1364}{requestedInoffice1365}{requestedInoffice1366}{requestedInoffice1367}

    • Requested In-Office Date: 
    • Image field 1369
    • Clinicians can still coordinate special in-office requests by emailing:
      HFN_Hypercare@hanger.com

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