CROW

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.
NextGen Encounter ID:
CROW

Intake Information
Patient ID:*
PO or Encounter #:*
Clinician Name - Deprecated:*
Clinician Name:*

First NameLast Name
Fabrication Location:*
HFN Rocky Hill (Cromwell) has relocated! Our new address is:
31 Inwood Rd, Rocky Hill, CT 06067
Other Fabrication Location:*
External
Fab PCC#:*
Fab Location:
Please enter a correct Fab PCC#
Clinician Email:*
Please enter to receive confirmation.
Clinician Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
- LeftRight
- Age:*
- lbskg
- Weight:*
- Weight:*
- Diagnosis:
- Physical Cast
- Submission Type:
  - Plaster Cast: Negative or Positive
    
    Please include a printed Work Order with the cast when shipping.
- The Shipping section is now at the end of the form.
- F0010 - AFO, CROW WALKER

CROW

Configurator
Notes:

0/250
- ImpressionMeasurements
- incm
- Finished Orthosis Height: *
  Decimal value optional
- Anatomical Foot Length (Weight Bearing):*
  Decimal value optional
- Malleoli ML:*
  Decimal value optional
- Met Head ML:*
  Decimal value optional
- Finished Orthosis Height: *
  Decimal value optional
- Anatomical Foot Length (Weight Bearing):*
  Decimal value optional
- Malleoli ML:*
  Decimal value optional
- Met Head ML:*
  Decimal value optional
- Indicate areas of sensitivities or ulcers:
- *Weight Bearing Foot Tracing or Foot Impression Required.
- Download CROW Weight Bearing Foot Tracing Sheet. Include the filled out sheet with the Work Order print out when shipping Cast.
  
  .
- Upload Filed out CROW Weight Bearing Foot Tracing Sheet:
  
  Accepted File types (Image only): jpg, jpeg, gif, png
  Cancelof
- Please provide cast in finished device alignment. Corrections are limited to +/- 5° in the sagittal plane.
- As CastedCorrect to NeutralOther
- Final Ankle Position:
- Set the Ankle in Degrees* ° of Dorsiflexion Plantarflexion*
- Ankle correction Limit
- Corrections are limited to +/- 5° in the sagittal plane.
- StandardTMA/Toe Filler
- Standard (actual foot length + 3/8")Extended Foot Length
- Extended Foot Length:
  Decimal value optional
- Extended Foot Length:
  Decimal value optional
- YesNo
- Sole Type (Rockers):*
- HeelAnkle JointMetheadLisfrancMPJHealing
- Draw the shape of key dimensions if needed:
- 12
- Plastic/Padding
- AliplastPlastazote
- PolypropyleneCopolymerProComp
- i
  
  Finished Plastic Thickness will be within 10% of the requested thickness.
- 1/8" (3 mm)3/16" (5 mm)1/4" (6 mm)
- 1/8" (3 mm)3/16" (5 mm)1/4" (6 mm)
- 5/32" (4 mm)3/16" (5 mm)1/4" (6 mm)
- 1/8" (3 mm)3/16" (5 mm)1/4" (6 mm)
- White/Natural PlasticBlack PlasticStocked Transfer PaperSpecial Order Transfer Paper
- Description and Part #*
  Special Order Transfer Paper
- Special Order Transfer Papers can increase device turnaround time.
- Stocked Transfer Paper #1:*
- Stocked Transfers:*
- Friddles Transfers:*
- NewLimbits Transfers:*
- Pink-PurpleBlueBlackRedYellowPurp ButterflySpringButterflyLeopardTornadoIceAgeSolarCarbonPlusBlueDropsDarkSkyPawPrintManhattanBlueSnakeJungleAnimalGeometricCamoSharks_NLSharks_FriddlesFlyNDriveBlueBatsKoolKraftGalacticSpaceSportsDinoBlueCartoonUnicornsFlutterHeartsSweetheartPurpleUnicornsUnicornDreamIceCreamStarlightOceanCrunchMilitaryCamoReaperBuckBearArmsAmericanFlagsZebraHeartsNRosesTattooLotusFunkyCamoCaribbeanCandyCloudCosmosTanBrownOatmealSkin 0BSkin 02Skin 06Skin 08Skin 18
- Bear ArmsBrown DinosCarbon FiberFlutterheartsGalacticHeavy EquipmentHoney BearsKool KraftOcean PalsPink ButterfliesPlanetsPurple UnicornRealtree OriginalReaper BlackReaper BuckSharksSkin Tone 06Skin Tone 14Solid BlueSolid Light PinkSportsSuperflaugeTie DyeUnicorn DreamZombie Buck
- American FlagsPurple ButterflyCandy CloudCarbon PlusCarbonCaribbeanCosmosDark SkyDino Light BlueDino WhiteFly and Drive BlueFly and Drive WhiteGeometric CamoIce CreamIce AgeLeopardLight PinkOatmealPaw PrintSaved by the BellSharksSkullsSpring ButterflySupermanTornado
- Transfer # 1
- Stocked Transfer Paper #2:*
- Please make a backup selection:*
- Friddles Transfers:*
- NewLimbits Transfers:*
- Pink-PurpleBlueBlackRedYellowPurp ButterflySpringButterflyLeopardTornadoIceAgeSolarCarbonPlusBlueDropsDarkSkyPawPrintManhattanBlueSnakeJungleAnimalGeometricCamoSharks_NLSharks_FriddlesFlyNDriveBlueBatsKoolKraftGalacticSpaceSportsDinoBlueCartoonUnicornsFlutterHeartsSweetheartPurpleUnicornsUnicornDreamIceCreamStarlightOceanCrunchMilitaryCamoReaperBuckBearArmsAmericanFlagsZebraHeartsNRosesTattooLotusFunkyCamoCaribbeanCandyCloudCosmosTanBrownOatmealSkin 0BSkin 02Skin 06Skin 08Skin 18Contact Practitioner
- Contact PractitionerBear ArmsBrown DinosCarbon FiberFlutterheartsGalacticHeavy EquipmentHoney BearsKool KraftOcean PalsPink ButterfliesPlanetsPurple UnicornRealtree OriginalReaper BlackReaper BuckSharksSkin Tone 06Skin Tone 14Solid BlueSolid Light PinkSportsSuperflaugeTie DyeUnicorn DreamZombie Buck
- Contact PractitionerAmerican FlagsPurple ButterflyCandy CloudCarbon PlusCarbonCaribbeanCosmosDark SkyDino Light BlueDino WhiteFly and Drive BlueFly and Drive WhiteGeometric CamoIce CreamIce AgeLeopardLight PinkOatmealPaw PrintSaved by the BellSharksSkullsSpring ButterflySupermanTornado
- Transfer # 2
- Duplicate Transfer
- PLEASE SELECT DIFFERENT OPTIONS FOR TRANSFER PAPERS.
- Reinforcement:
- CompcoreCorrugation
- 1"1.5"2"
- VelcroDacron ReinforcedLeather Backed
- WhiteBlackBeige
- WhiteBlackBeige
- WhiteBlackBeigeBluePurpleRedGreenLight Pink
- Leave Detached
- Chafe MedialChafe LateralButterfly (Double Chafe)
- GluedNot Glued
- GluedNot Glued

CROW

CROW

*Weight Bearing Foot Tracing or Foot Impression Required.

Plastic/Padding

Special Order Transfer Papers can increase device turnaround time.

CROW