UCB, SMO

  • 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. 

  • UCB, SMO

    Intake Information

  • HFN Rocky Hill (Cromwell) has relocated! Our new address is:
    31 Inwood Rd, Rocky Hill, CT 06067

  • Please enter a correct Fab PCC#

  • Format: (000) 000-0000.
    • Patient Information: 

    • Bilateral Symmetrical: 

      • Left and Right sides can have different Measurements
      • Same Alignment, Design and Finishing options

    • Please use the Special Order Pediatric UCB, SMO form for Non-Standard Pediatric Designs.
      This form cannot be used for patients under 18.

    • 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.

  • UCB, SMO

    Device Type

  • UCB, SMO

    Configurator
  • 0/250
    • 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      *        

    • If "As Casted" Forefoot Alignment is required, please select "Other" and provided the as casted alignment. 

    • 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 field 1047
    • Image field 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 field 1084
    • Image field 1085
    • Image field 1086
    • Image field 1087
    • Image field 1088
    • Image field 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 field 1094
    • Padding: 

    • Additional Padding

    • Finishing: 
    • Image field 1061
    • Image field 1098
    • Image field 1099

  • UCB, SMO

    Notes
  • 0/250
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  • Daily HFN Capacity

  • {requestedInoffice}{requestedInoffice1198}{requestedInoffice1199}{requestedInoffice1200}

    • Requested In-Office Date: 
    • Image field 1203

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

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