PLASTIC AFO w/COMPOSITE STRUT

PLASTIC AFO w/COMPOSITE STRUT

Access Legacy PDF work order. Legacy form will be accepted until Nov 1st.
Please do not print the Review page.

Scroll to the bottom, hit Complete and then download the work order.
NextGen Encounter ID:
PLASTIC AFO w/COMPOSITE STRUT

Intake Information
Patient ID:
PO or Encounter #:
Clinician Name - Deprecated:
Clinician Name:

First NameLast Name
Fabrication Location:
HFN Rocky Hill (Cromwell) has relocated! Our new address is:
31 Inwood Rd, Rocky Hill, CT 06067
Other Fab location:
Fab PCC #:
Fab Location:
Please enter a correct Fab PCC#
Clinician Email:
Please enter to receive confirmation.
Clinician Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
External
- Bilateral:
- Age:
- Bilateral Type:
- Affected Side:
- Bilateral Symmetrical:
  - Left and Right sides can have different Measurements
  - Same Alignment, Design and Finishing options
- Affected Side-Bilat Sym
- Affected Side-Bilat Asymmetrical
- Weight Unit:
- Activity Level:
- Weight:
- Weight:
- Diagnosis:
- Submission Type:
- Submission Type:
  - Plaster Cast: Negative or Positive
    
    Please include a printed Work Order with the cast when shipping.
- Scan being submitted with order:
- The Scan Upload is available at the end of the Form.
- 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.

PLASTIC AFO w/COMPOSITE STRUT

Device Type
Raven Base Code:
Device Type
Device Type:
Device Type - Ant Shell Option:

PLASTIC AFO w/COMPOSITE STRUT

Configurator
Notes:

0/250
GUIDANCE

• Any brace with a flat toe plate will require shoe work to function
• Any brace without a contoured foot plate/toe ramp is prone to fail
- Go by:
- Please indicate measurement unit:
- LEFT Selection
- RIGHT Selection
- L - Fib Head to Casting platform Height:
  Decimal value optional
- R - Fib Head to Casting platform Height:
  Decimal value optional
- Fib Head to Cast Platform Height Container
- L - Casting Block Height:
  Decimal value optional
- R - Casting Block Height:
  Decimal value optional
- Casting Block Height Container
- L - Knee Center to Heel:
  Decimal value optional
- R - Knee Center to Heel:
  Decimal value optional
- Knee Center to Heel Container
- L - MTP to Heel:
  Decimal value optional
- R - MTP to Heel:
  Decimal value optional
- MTP to Heel Container
- L - Distal Thigh ML:
  Decimal value optional
- R - Distal Thigh ML:
  Decimal value optional
- Distal Thigh ML Container
- L - Calf Height:
  Decimal value optional
- R - Calf Height:
  Decimal value optional
- Calf Height Container
- L - Calf Circ:
  Decimal value optional
- R - Calf Circ:
  Decimal value optional
- Calf Circ Container
- L - Calf ML:
  Decimal value optional
- R - Calf ML:
  Decimal value optional
- Calf ML Container
- L - Mid Calf Height:
  Decimal value optional
- R - Mid Calf Height:
  Decimal value optional
- Mid Calf Height Container
- L - Mid Calf Circ:
  Decimal value optional
- R - Mid Calf Circ:
  Decimal value optional
- Mid Calf Circ Container
- L - Mid Calf ML:
  Decimal value optional
- R - Mid Calf ML:
  Decimal value optional
- Mid Calf ML Container
- L - Ankle ML:
  Decimal value optional
- R - Ankle ML:
  Decimal value optional
- Ankle ML Container
- L - Ankle Joint Height:
  Decimal value optional
- R - Ankle Joint Height:
  Decimal value optional
- Ankle Joint Height Container
- L - Met Head ML (Semi-weight bearing):
  Decimal value optional
- R - Met Head ML (Semi-weight bearing):
  Decimal value optional
- Met Head ML Container
- L - Anatomical Foot Length (Weight Bearing):
  Decimal value optional
- R - Anatomical Foot Length (Weight Bearing):
  Decimal value optional
- Anatomical Foot Length Container
- L - Finished Orthosis Height:
  Decimal value optional
- R - Finished Orthosis Height:
  Decimal value optional
- Finished Orthosis Height Container
- L - Finished Plastic Footplate length:
  Decimal value optional
- R - Finished Plastic Footplate length:
  Decimal value optional
- Finished Plastic Footplate Container
- L - Fib Head to Casting platform Height:
  Decimal value optional
- R - Fib Head to Casting platform Height:
  Decimal value optional
- L - Casting Block Height:
  Decimal value optional
- R - Casting Block Height:
  Decimal value optional
- L - Knee Center to Heel:
  Decimal value optional
- R - Knee Center to Heel:
  Decimal value optional
- L - MTP to Heel:
  Decimal value optional
- R - MTP to Heel:
  Decimal value optional
- L - Distal Thigh ML:
  Decimal value optional
- R - Distal Thigh ML:
  Decimal value optional
- L - Calf Height:
  Decimal value optional
- R - Calf Height:
  Decimal value optional
- L - Calf Circ:
  Decimal value optional
- R - Calf Circ:
  Decimal value optional
- L - Calf ML:
  Decimal value optional
- R - Calf ML:
  Decimal value optional
- L - Mid Calf Height:
  Decimal value optional
- R - Mid Calf Height:
  Decimal value optional
- L - Mid Calf Circ:
  Decimal value optional
- R - Mid Calf Circ:
  Decimal value optional
- L - Mid Calf ML:
  Decimal value optional
- R - Mid Calf ML:
  Decimal value optional
- L - Ankle ML:
  Decimal value optional
- R - Ankle ML:
  Decimal value optional
- L - Ankle Joint Height:
  Decimal value optional
- R - Ankle Joint Height:
  Decimal value optional
- L - Met Head ML (Semi-weight bearing):
  Decimal value optional
- R - Met Head ML (Semi-weight bearing):
  Decimal value optional
- L - Anatomical Foot Length (Weight Bearing):
  Decimal value optional
- R - Anatomical Foot Length (Weight Bearing):
  Decimal value optional
- L - Finished Orthosis Height:
  Decimal value optional
- R - Finished Orthosis Height:
  Decimal value optional
- L - Finished Plastic Footplate length:
  Decimal value optional
- R - Finished Plastic Footplate length:
  Decimal value optional
- i
  
  NEUTRAL is the Tibia perpendicular to the floor based on Heel Height.
- Ankle Alignment:
- Final Ankle Position:
- Set the Ankle in Degrees* ° of Dorsiflexion Plantarflexion*
- Ankle Degrees container
- Heel Height Accommodation:
- Forefoot Alignment:
- If "As Casted" Forefoot Alignment is required, please select "Other" and provided the as casted alignment.
- Forefoot Alignment Container:
- Final Forefoot Position:
- Set the Forefoot in Degrees* ° of Varus Valgus*
- Forefoot Degrees container
- Foot Rotation:
- Set the foot in Degrees* ° of External Internal* Rotation.
- Hindfoot Alignment:
- Final Hindfoot Position:
- Set the Hindfoot in Degrees* ° of Inversion Eversion*
- Hindfoot Degrees container
- Rocker:
- Toe Ramp/Extension Angle:
- Rocker Container:
- Buildups/Reductions:
- 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.
- Met Heads:
- Medial Malleolus:
- Lateral Malleolus:
- Navicular:
- Base of the 5th:
- Posterior Heel (pump bump):
- Medial Longitudinal Arch Apex Reduction:
- Dorsum:
- Foot Mod Add ons:
- Intrinsic Heel Skive:
- Skive Magnitude:
- Intrinsic Heel Skive requires external posting/wedging.
- Trimline Profile:
- - Standard: 1/8" deflection from the leg with extra accommodation at the malleoli to reduce edge pressure.
- - Gutter: Material added to create a "gutter" shape so the trimlines are inline with the apex of the buildups. (Commonly used for Positioning or Night time Stretching AFOs).
- Gutter Trimline Profile Location:
- Midfoot Trimline Default:
- Midfoot Trimline:
- L - Heel to Dorsum Circumference:
  Decimal Value Optional
- R - Heel to Dorsum Circumference:
  Decimal Value Optional
- Heel to Dorsum Container:
- L - Instep Circumference:
  Decimal Value Optional
- R - Instep Circumference:
  Decimal Value Optional
- Instep Circ Container:
- L - Heel to Dorsum Circumference:
  Decimal value optional
- R - Heel to Dorsum Circumference:
  Decimal value optional
- L - Instep Circumference:
  Decimal value optional
- R - Instep Circumference:
  Decimal value optional
- Midfoot Trimline:
- Midfoot Trimline:
- Plastic Footplate Trimline Default:
- Plastic Footplate Trimline:
- Footplate Trimline:
- Forefoot Trimline Default:
- Forefoot Trimline:
- Forefoot Trimline:
- Additional Options:
- Left Supramalleolar Extension:
- Right - Supramalleolar Extension:
- Composite Strut Options:
- Trulife Neuro Spring Length:
- Trulife Neuro Firmness (Soft to Firm):
- PDE Neuro Spring Length:
- PDE Kids Spring Length:
- PDE Neuro Firmness (Soft to Firm):
- PDE Kids Firmness (Soft to Firm):
- Coyote Firmness (Extra Soft to Extra Rigid):
- Posting/Wedging:
- Posting:
- External Heel Wedge:
- Specify Amount:
  Decimal value optional
- Specify Amount:
  Decimal value optional
- Posting options will not be available if a Heel Wedge is selected.
- {intrinsicHeel990} Intrinsic Heel Skive was selected.
- Heel Post:
- Heel Post Material:
- External Forefoot Post:
- External Forefoot Post Material:
- Plastic
- i
  
  Finished Plastic Thickness will be within 10% of the requested thickness.
- Plastic Type:
- Anterior Shell Plastic Type:
- Finished Plastic Thickness:
- Anterior Finished Plastic Thickness:
- Finished Plastic Thickness:
- Anterior Finished Plastic Thickness:
- Plastic Color/Transfer:
- Description and Part #:
  Special Order Transfer Paper
- Special Order Transfer Papers can increase device turnaround time.
- Stocked Transfer Paper #1:
- Stocked Transfers:
- NewLimbits Transfers:
- NewLimbits Transfers Container #1
- Stocked Transfers Container #1
- Transfer # 1
- Stocked Transfer Paper #2:
- Please make a backup selection:
- NewLimbits Transfers:
- NewLimbits Transfers Container #2
- Stocked Transfers Container #2
- Transfer # 2
- Duplicate Transfer
- PLEASE SELECT DIFFERENT OPTIONS FOR TRANSFER PAPERS.
- Reinforcement:
- Reinforcement:
- Inner Boot:
  
  Other
- Inner Boot Thickness:
- Inner Boot Thickness:
- L - Heel to Dorsum Circumference:
  Decimal value optional
- R - Heel to Dorsum Circumference:
  Decimal value optional
- L - Instep Circumference:
  Decimal value optional
- R - Instep Circumference:
  Decimal value optional
- L - Heel to Dorsum Circumference:
  Decimal value optional
- R - Heel to Dorsum Circumference:
  Decimal value optional
- L - Instep Circumference:
  Decimal value optional
- R - Instep Circumference:
  Decimal value optional
- Full Device Padding Type:
- Full Device Padding Thickness:
- Supramalleolar Ext. Padding Type:
- Supramalleolar Ext. Padding Thickness:
- Plantar Surface Padding Type:
- Plantar Surface Padding Thickness:
- Additional Padding
- Anterior Shell Padding Type:
- Anterior Shell Padding Thickness:
- Malleoli Padding:
- Malleoli Padding Type:
- Malleoli Padding Thickness:
- Calf Padding Type:
- Calf Padding Thickness:
- Navicular Padding Type:
- Navicular Padding Thickness:
- Empty
- Additional Padding Insertion:
- Fastener Type:
- Standard Fastener Type:
- Strap Type:
- Standard Strap Type:
- Leather Strap Color:
- Dacron Strap Color:
- Velcro Strap Color:
- Standard Strap Color:
- Calf Strap Width:
- Standard Strap Width:
- Calf Strap Placement:
- Calf Strap:
- Standard Strap Placement:
- Proximal Ankle Strap Width:
- Proximal Ankle Strap Placement:
- Proximal Ankle Strap:
- Instep Strap Width:
- Instep Strap Placement:
- Instep Strap:
- Corrective:
- Instep Strap Style:
- Add-Ons:
- Non-Skid Surface:

PLASTIC AFO w/COMPOSITE STRUT

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)
Scan Upload:

Accepted File types: med, fsn, op3, stl - 60 MB File Size Limit
Cancelof
Average Cast Thickness - Left (mm):
Decimal Value Optional
Average Cast Thickness - Right (mm):
Decimal Value Optional
Outside Cast Forefoot ML - Left (mm):
Decimal Value Optional
Outside Cast Forefoot ML - Right (mm):
Decimal Value Optional
Outside Cast Ankle ML - Left (mm):
Decimal Value Optional
Outside Cast Ankle ML - Right (mm):
Decimal Value Optional
Technical Consult: I would like a call to discuss prior to starting fabrication.
Who would you like a call from?
Technical Consult Team:
Notes:

0/250
Upload Supporting Images (Optional):

Allowed Image types: jpg, jpeg, png, gif
Cancelof
Return Shipping Method:
Return Shipping Method:
Return Shipping Method:
Shipping is same as Billing Address:
Right answer
Bill to PCC#:
Ship to PCC#:
Ship to Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Bill to Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Bill to Address:
Hospital Call/Fast Track:
Requested In-Office Date:

MonthDayYear
Order ship date may be impacted by incomplete order, component availability and upon cast receipt (for physical orders).
Requested In-Office Date:

MonthDayYear
Order ship date may be impacted by incomplete order, component availability and upon cast receipt (for physical orders).
Requested In-Office Date:

MonthDayYear
Order ship date may be impacted by incomplete order, component availability and upon cast receipt (for physical orders).
Requested In-Office Date:

MonthDayYear
Order ship date may be impacted by incomplete order, component availability and upon cast receipt (for physical orders).
Daily HFN Capacity
Hospital Call/Fast Track
{requestedInoffice}{requestedInoffice1408}{requestedInoffice1409}{requestedInoffice1410}
- Clinicians can still coordinate special in-office requests by emailing:
  HFN_Support@hanger.com
- Bilateral
- - F0036
- - F2600
- - F0051
- - F2840
- - F2860
- - F2820
- - F1915
- - F0040
- - F0040
- - F3310
- - F0046
- - F0046
- - F0047
- - F0053
- - P1000
- Raven Component Codes:
- Composite Strut:
- Today's Date:
  
  MonthDayYear
  Date
  Hour MinutesAM/PM Option
Should be Empty: