SPECIAL ORDER PEDIATRIC 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. 

  • SPECIAL ORDER PEDIATRIC UCB/SMO

    Intake Information

  • Please enter a correct Fab PCC#

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

    • Bilateral Symmetrical: 

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

    • Please use the UCB, SMO form for Adult patients. This form is 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.

  • SPECIAL ORDER PEDIATRIC UCB/SMO

    Device Type
  • Raven Base Code:
  • Device Type

  • SPECIAL ORDER PEDIATRIC UCB/SMO

    Configurator
  • 0/250
    • Measurements: 
    • Go by:*
    • Please indicate measurement unit:*
    • Patient Measurements
    • Patient Measurements
    • Patient Measurements
    • Patient Measurements
    • 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:

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

    • Final Forefoot Position:

    • Set the Forefoot in   *   ° of      *        

    • Hindfoot Alignment*

    • Final Hindfoot Position:

    • Set the Hindfoot in   *   ° of      *              

    • Modifications/Trimlines: 
    • 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:
    • Image field 1047
    • Image field 1048
    • Foot Mod Add ons:
    • Intrinsic Heel Skive:*
    • Skive Magnitude:*

    • Intrinsic Heel Skive requires external posting.

    • i

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

    • Midfoot Trimline Default:
    • Midfoot Trimline:

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

    • Plastic Footplate Trimline Default:
    • Footplate Trimline:
    • Forefoot Trimline Default:
    • Forefoot Trimline:
    • Materials/Design: 

    • Posting:

    • {intrinsicHeel990} Intrinsice Heel Skive was selected. 

    • Heel Post:
    • Heel Post Material:*
    • Image field 1084
    • Image field 1085
    • Image field 1086
    • External Forefoot Post:
    • External Forefoot Post Material:*
    • Image field 1087
    • Image field 1088
    • Image field 1089

    • Plastic

    • i

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

    • Plastic Type:*
    • Finished Plastic Thickness*
    • Plastic Color/Transfer:*

    • Special Order Transfer Papers can increase device turnaround time.

    • Stocked Transfers Container #1
    • NewLimbits Transfers Container #1
    • Friddles Transfers Container #1
    • Stocked Transfers Container #2
    • NewLimbits Transfers Container #2
    • Friddles Transfers Container #2

    • PLEASE SELECT DIFFERENT OPTIONS FOR TRANSFER PAPERS.

    • Inner Boot:
    • Inner Boot Thickness:*
    • Inner Boot Thickness:*
    • Image field 1094
    • Padding: 
    • Full Device Padding Thickness:*
    • Plantar Surface Padding Thickness:*

    • Additional Padding

    • Malleoli Padding:
    • Malleoli Padding Thickness:*
    • Navicular Padding Thickness:*
    • Horseshoe/Heel Padding Thickness:*
    • Additional Padding Insertion:
    • Finishing: 
    • Fastener Type:*
    • Strap Type:*
    • Leather Strap Color:*
    • Dacron Strap Color:*
    • Velcro Strap Color:*
    • Instep Strap Width:
    • Instep Strap Placement:*
    • Instep Strap Style:*
    • Image field 1061
    • Image field 1098
    • Image field 1099
    • Add-Ons:

  • SPECIAL ORDER PEDIATRIC UCB/SMO

    Notes
  • Who would you like a call from?*
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  • Return Shipping Method:
  • Shipping is same as Billing Address:*
  • Requested In-Office Date:
     - -
  • Requested In-Office Date:
     - -
  • Requested In-Office Date:
     - -
  • Requested In-Office Date:
     - -
  • Requested In-Office Date:*
     - -
  • Requested In-Office Date:*
     - -

  • Daily HFN Capacity

  • This option is for requests requiring a 24–48 hour turnaround. An expedite fee might apply.

  • {requestedInoffice}{requestedInoffice1199}{requestedInoffice1200}{requestedInoffice1201}

    • Requested In-Office Date: 
    • Image field 1204

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

    • Today's Date:*
       - -
  • Should be Empty: