RICHIE STYLE AFO

  • 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. 

  • RICHIE STYLE AFO

    Intake Information

  • Please enter a correct Fab PCC#

  • 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:
    • Deprecated - Scan being submitted with order - 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. 

    • 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.

  • RICHIE STYLE AFO

    Device Type
  • Device Type:*
  • Options:

  • Black Plastic. No Transfers available for this selection.

  • Raven Base Code:

  • RICHIE STYLE AFO

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

      • 1/8" (3 mm) buildup at the Malleoli
    • Met Heads:
    • Medial Malleolus:
    • Lateral Malleolus:
    • Navicular:
    • Base of the 5th:
    • Posterior Heel (pump bump):
    • Medial Longitudinal Arch Apex Reduction:
    • Image field 1192
    • Foot Mod addons:
    • Intrinsic Heel Skive:*
    • Image field 1114
    • Skive Magnitude:*

    • Intrinsic Heel Skive requires external posting.

    • Heel Cup:*

    • i

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

    • Midfoot Trimline Default:
    • Midfoot Trimline:

    • Provided Finished Plastic Foot Plate Length: {finishedFootplate1000}{finishedFootplate}

    • Plastic Footplate Trimline Default:

    • Provided Finished Top Cover Length: {finishedTop}{finishedTop1078}

    • Plastic Footplate Trimline:
    • Top Cover Length Default:
    • Top Cover Length:
    • Forefoot Trimline Default:
    • Forefoot Trimline:
    • Materials/Design: 

    • Ankle Joints:

    • Joints:*
    • Tamarack with Dorsiflexion Assist:*

    • Posting:

    • Crepe Heel Post:
    • Image field 1140
    • Image field 1141
    • Image field 1142
    • Crepe External Forefoot Post:
    • Image field 1145
    • Image field 1143
    • Image field 1144

    • Plastic

    • 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.

    • Top Cover:*
    • Finishing: 
    • Add-Ons:
    • Image field 1124
    • Image field 1125
    • Instep Strap Width:
    • Instep Strap Placement:*
    • Instep Strap Style:*
    • Image field 1123
    • Image field 1126
    • Image field 1149

  • RICHIE STYLE 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:*
  • Who would you like a call from?*
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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

  • {requestedInoffice1035}{requestedInoffice1280}{requestedInoffice1281}{requestedInoffice1282}{requestedInoffice1283}{requestedInoffice1284}{requestedInoffice1285}

    • Requested In-Office Date: 
    • Image field 1278

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

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