Thermoplastic AFO Fabrication - Legacy Devices

DAFO Style
DAFO
Patient Name:*

First InitialLast Name
Encounter # / PO #:*
Practitioner:*
Clinic Location:*
Email*
Please enter to receive confirmation.
Today's Date:*

MonthDayYear
Date
Due Date:

MonthDayYear
Date

DAFO Style

Patient Information
Affected Side:*

LeftRight
Diagnosis:*
Weight:*
Age*

DAFO Style

Device Type
Left - Device Type

DAFO Style #___
Right - Device Type

DAFO Style #___
DAFO Style #___*
DAFO Style #___*

DAFO Style

Measurements
Build from mold (measurements not required):*

YesNo (correct mold to measurements provided, then modify)
Left - Measurements:
Right - Measurements:
Left - Trim Height:*
Right - Trim Height:*

DAFO Style

Notes
I would like a phone call to discuss this project prior to starting fabrication

Yes
Notes:

0/50
Should be Empty: