ECO/LEATHER AFO GAUNTLETS/MBB

  • Please do not print the Review page.

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

  • Access Legacy PDF work order. Legacy form will be accepted until Aug 15th. 

  • ECO/LEATHER AFO GAUNTLETS/MBB

    Intake Information
  • 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
    • Weight Unit:
    • Scan being submitted with order (Deprecated - Do Not Delete:*
    • Submission Type:*

    • Save $15 + no outbound shipping/downtime + front-of-the-line processing with Scan/Hanger 3D app orders

    • 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. 

    • Date:*
       - -
    • 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. 

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

  • ECO/LEATHER AFO GAUNTLETS/MBB

    Device Type
  • Device Type
  • Raven Base Code:

  • ECO/LEATHER AFO GAUNTLETS/MBB

    Configurator
  • 0/250
    • Measurements: 
    • Go by:*
    • Please indicate measurement unit:*
    • Image field 347
    • Image field 965
    • Image field 966
    • Alignment: 

    • i

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

    • Ankle Alignment:*

    • Final Ankle Position:

    • Set the Ankle in   *   ° of      *        

    • 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: 
    • Buildups/Reductions:

    • Standard Mods include:

      • 3/16" (5 mm) buildup at the Malleoli
      • 1/8" (3 mm) build up at the Navicular, Base of the 5th and Met heads.  
    • Met Heads:
    • Medial Malleolus:
    • Lateral Malleolus:
    • Navicular:
    • Base of the 5th:
    • Posterior Heel (pump bump):
    • Medial Longitudinal Arch Apex Reduction:
    • Image field 1028
    • Foot Mod Add ons:
    • Intrinsic Heel Skive:
    • Image field 954
    • Skive Magnitude:*

    • Intrinsic Heel Skive requires external posting.

    • Midfoot Trimline Default:
    • Midfoot Trimline:

    • Provided Finished Foot Plate Length: {finishedFootplate}{finishedFootplate926}

    • Footplate Trimline Default:
    • Footplate Trimline:
    • Forefoot Trimline Default:
    • Forefoot Trimline:

    • Trimlines

    • Inner Frame Trimlines:*
    • Image field 978
    • Materials/Design: 

    • Posting:

    • Heel Post:
    • Image field 979
    • Image field 980
    • Image field 981
    • Heel Post Amount:

    • Ankle Joints

    • Joints:*
    • Tamarack w/Dorsiflexion Assist:*

    • i

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

    • Plastic Type:*
    • Finished Plastic Thickness*
    • Finished Plastic Thickness*
    • Exterior Material:*
    • Material Color:*
    • Material Color:*
    • Image field 958
    • Image field 959
    • Image field 960
    • Image field 961
    • Image field 962
    • Padded Collar:

    • Padded Collar required for EcoTex. 

    • Finishing: 
    • Closure Type:*
    • Closure Type:*
    • Image field 956
    • Image field 957

    • Adjustable Reel available with Leather only. 

    • Strap Width:*
    • Strap Placement:

  • ECO/LEATHER AFO GAUNTLETS/MBB

    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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  • Return Shipping Method:
  • Shipping is same as Billing Address:*
  • Requested In-Office Date:
     - -
  • Requested In-Office Date:
     - -
  • Requested In-Office Date:
     - -
  • Requested In-Office Date:
     - -
  • Requested In-Office Date:
     - -
  • Requested In-Office Date:
     - -
  • Requested In-Office Date:
     - -

  • Daily HFN Capacity

  • {requestedInoffice}{requestedInoffice1112}{requestedInoffice1113}{requestedInoffice1114}{requestedInoffice1115}{requestedInoffice1116}{requestedInoffice1117}

    • Requested In-Office Date: 
    • Image field 1120

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

    • Today's Date:*
       - -
  • Should be Empty: