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  • Agilik KAFO/HKAFO

    Intake Information
  • Format: (000) 000-0000.
    • Patient Information: 
    • Bilateral:*
    • Bilateral Type:*
    • Affected Side:*
    • Weight Unit:*

    • There is a max weight limit of 160 kg/352 lbs. 

    • Medial Knee Joint (17K45) required for patients over 154 lbs (70 kg). 

    • Is this a Warranty return?*

    • 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.

    • Activity Level:
    • Raven Base Code:
    • Device Type:

  • Agilik KAFO/HKAFO

    Configurator
  • 0/250
    • Casting 
    • Please indicate measurement unit:*

    • TWO STAGE CAST IS REQUIRED

    • Image field 1214
    • Image field 1216
    • Image field 1217

    • ALIGNMENT CASTING BLOCK:

    • Medial Knee Joint (17K45) required for this Knee Extension angle.

    • Toe Ramp Angle:

      • Low < 10° – household ambulators with limited community ambulation
      • Moderate 12-15° – community ambulator
      • High 15-30° – active community ambulators
    • Toe Ramp Angle:*
    • Measurements 
    • Image field 1196
    • Image field 1225

    • If a candidate's knee center to trochanter length is less than 25 cm, the device cannot be fabricated. This is due to the actuator attachment points length exceeding the available segment length.

    • If a candidate's knee center to trochanter length is less than 10 in, the device cannot be fabricated. This is due to the actuator attachment points length exceeding the available segment length.

    • Is an HKAFO/RGO required?
    • Image field 1232
    • Rows
    • Rows
    • Rows
    • Rows
    • 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:*

    • Final Forefoot Position:

    • Set the Forefoot in   *   ° of      *        

    • Hindfoot Alignment:*

    • Final Hindfoot Position:

    • Set the Hindfoot in   *   ° of      *        

    • Sagittal Knee Alignment:*

    • Final Knee Position (Sagittal Plane):

    • Set the Knee in   *   ° of      *        

    • Coronal Knee Alignment:*

    • Final Knee Position (Coronal Plane):

    • Set the Knee in   *   ° of      *        

    • Modifications: 
    • Buildups/Reductions:

    • Standard Mods include:

      • 3mm (1/8") buildup at the Malleoli, Navicular and Base of the 5th. 
      • 3mm (1/8") reduction at the Medial Longitudinal Arch Apex. 
    • Met Heads:
    • Medial Malleolus:
    • Lateral Malleolus:
    • Navicular:
    • Base of the 5th:
    • Posterior Heel (pump bump):
    • Medial Longitudinal Arch Apex Reduction:
    • Image field 1263
    • Image field 1264
    • Foot Mod Add ons:
    • Intrinsic Heel Skive:*
    • Skive Magnitude:*
    • Materials/Design: 

    • Posting:

    • {intrinsicHeel990} Intrinsic Heel Skive was selected. 

    • Heel Post:
    • Heel Post Material:*
    • Image field 1283
    • Image field 1284
    • Image field 1285
    • External Forefoot Post:
    • External Forefoot Post Material:*
    • Image field 1289
    • Image field 1290
    • Image field 1291

    • Joints:

    • Image field 1326

    • Ankle Joints:

    • Lateral Ankle Joint (MiLine Double Action Joint with Posterior Booster):*
    • Medial Ankle Joint (MiLine Double Action Joint):*
    • Lateral Ankle Joint (MiLine Double Action Joint with Posterior Booster):*
    • Medial Ankle Joint (MiLine Double Action Joint):*

  • Agilik KAFO/HKAFO

    Notes
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  • Return Shipping Method:
  • Shipping is same as Billing Address:*
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  • Daily HFN Capacity

  • {requestedInoffice}{requestedInoffice1354}{requestedInoffice1355}

    • Requested In-Office Date: 
    • Image field 1358

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

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