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:
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.
- Affected Side:
- Age:
- Weight Unit:
- Weight:
- Weight:
- Diagnosis:
- Submission Type:
- 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.
- Raven Base Code:

CROW

Configurator
Notes:

0/250
- Go by:
- Please indicate measurement unit:
- 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.
- Ankle Alignment:
- Final Ankle Position:
- Set the Ankle in Degrees* ° of Dorsiflexion Plantarflexion*
- Ankle correction Limit
- Corrections are limited to +/- 5° in the sagittal plane.
- Device Type:
- Modifications:
- Extended Foot Length:
  Decimal value optional
- Extended Foot Length:
  Decimal value optional
- Proximal Flare:
- Sole Type (Rockers):
- Sole Type (Rockers) Container:
- Draw the shape of key dimensions if needed:
- Additional Foot Inserts:
- Plastic/Padding
- Padding Type:
- Plastic Type:
- i
  
  Finished Plastic Thickness will be within 10% of the requested thickness.
- Finished Posterior Plastic Thickness:
- Finished Posterior Plastic Thickness:
- Finished Anterior Plastic Thickness:
- Finished Anterior Plastic Thickness:
- Plastic Color/Transfer:
- 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:
- Stocked Transfers Container #1
- NewLimbits Transfers Container #1
- Friddles Transfers Container #1
- Transfer # 1
- Stocked Transfer Paper #2:
- Please make a backup selection:
- Friddles Transfers:
- NewLimbits Transfers:
- Stocked Transfers Container #2
- NewLimbits Transfers Container #2
- Friddles Transfers Container #2
- Transfer # 2
- Duplicate Transfer
- PLEASE SELECT DIFFERENT OPTIONS FOR TRANSFER PAPERS.
- Reinforcement:
- Reinforcement:
- Strap Width:
- Strap Type:
- Leather Strap Color:
- Dacron Strap Color:
- Velcro Strap Color:
- Strap Attachment:
- Strap Chafe Placement:
- Non-Skid Surface:
- Non-Skid Surface:

CROW

CROW

*Weight Bearing Foot Tracing or Foot Impression Required.

Plastic/Padding

Special Order Transfer Papers can increase device turnaround time.

CROW