XOS Brace

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.

Please enter to receive confirmation.

Please enter a valid phone number.Format: (000) 000-0000.

Symmetrical (Single Work order)Asymmetrical (Separate Work orders for each side)

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.

F1946 - XOS WITHOUT BOAF1947 - XOS WITH BOA

XOS WITHOUT BOAXOS WITH BOA

Please order an XOS Kit.

Casting block Height and Toe Ramp Angle measurements are recommended.
If Heel Wedging alone is required, please proceed to the Materials/Design Section.

As CastedSet in NeutralOther

Final Ankle Position (Ankle Angle):

Set the Ankle in Degrees* ° of Dorsiflexion Plantarflexion*

Calculate from Cast Block SetupBase off SVASpecified Amount

Decimal value optional

ImpressionMeasurements

PTB DesignAnterior ShellLeather A/P

StandardPartial Foot

Single StrapAdjustable Reel Strap

CarbonPigmentedCustom Fabric

Strut is provided with the kit.
Complete this section only if the design deviates from kit.

Modifications (Modifier)Design options on device (Fab Supervisor)Shipping/Billing (Customer Support)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Order ship date may be impacted by incomplete order, component availability and upon cast receipt (for physical orders).

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

Date

Hour MinutesAM/PM Option

XOS BRACE

XOS BRACE

XOS BRACE