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

  • Legacy form will no longer be accepted. 

  • Please do not print the Review page.

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

  • UCB, SMO

    Intake Information

  • Please enter a correct Fab PCC#

  •  - -

  • Daily HFN Capacity

  •  - -

  • UCB, SMO

    Patient Information

  • Please use the Special Order Pediatric form for Non-Standard Pediatric Designs.

  • UCB, SMO

    Device Type

  • UCB, SMO

    Configurator
    • Measurements: 
    • Patient Measurements
    • Patient Measurements
    • Patient Measurements
    • Patient Measurements
    • Alignment: 

    • i

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

    • Final Ankle Position:

    • Set the Ankle in   *   ° of      *        

    • Final Forefoot Position:

    • Set the Forefoot in   *   ° of      *        

    • Final Hindfoot Position:

    • Set the Hindfoot in   *   ° of      *              

    • Modifications/Trimlines: 

    • Standard Mods include:

      • 1/8" (3 mm) buildup at the Malleoli, Navicular and Base of the 5th. 
      • 1/8" (3 mm) reduction at the Medial Longitudinal Arch Apex. 
    • Image-1047
    • Image-1048

    • Intrinsic Heel Skive requires external posting.

    • i

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

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

    • Materials/Design: 

    • Posting:

    • {intrinsicHeel990} Intrinsice Heel Skive was selected. 

    • Image-1084
    • Image-1085
    • Image-1086
    • Image-1087
    • Image-1088
    • Image-1089

    • Plastic

    • i

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

    • Special Order Transfer Papers can increase device turnaround time.

    • PLEASE SELECT DIFFERENT OPTIONS FOR TRANSFER PAPERS.

    • Image-1094
    • Padding: 

    • Additional Padding

    • Finishing: 
    • Image-1061
    • Image-1098
    • Image-1099

  • UCB, SMO

    Notes
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