METAL/HYBRID AFO

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.
METAL/HYBRID AFO

Intake Information
Patient ID:*

First InitialLast Name
PO or Encounter #:*
Clinician Name:*
Fabrication Location:*
Clinician Email:*
Please enter to receive confirmation.
Clinician Phone Number:*
Please enter a valid phone number.
Requested In-Office Date:

MonthDayYear
Date
Daily HFN Capacity
External
Return Shipping Method:

Ground2-dayPriority OvernightFirst OvernightLocal CourierPick up
Return Shipping Method:*
Shipping is same as Billing Address:*

YesNo
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:*
Today's Date:*

MonthDayYear
Date

METAL/HYBRID AFO

Configurator
Please indicate measurement unit:*

incm

Measurements:
Left - Selection
Right - Selection
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 - Distal Tip Medial Malleolus Height:*
Decimal value optional
R - Distal Tip Medial Malleolus Height:*
Decimal value optional
Distal Tip Medial Malleolus Height- Container:
L - Ankle ML:*
Decimal value optional
R - Ankle ML:*
Decimal value optional
Ankle ML - Container:
L - Met Head ML:*
Decimal value optional
R - Met Head ML:*
Decimal value optional
Met Head ML - Container:
L - Toe out˚:*
Degrees
R - Toe out˚:*
Degrees
Toe out˚ - Container:
L - Finished Footplate Length:*
Decimal value optional
R - Finished Footplate Length:*
Decimal value optional
Finished Footplate Length - Container:
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 - Distal Tip Medial Malleolus Height:*
Decimal value optional
R - Distal Tip Medial Malleolus Height:*
Decimal value optional
L - Ankle ML:*
Decimal value optional
R - Ankle ML:*
Decimal value optional
L - Met Head ML:*
Decimal value optional
R - Met Head ML:*
Decimal value optional
L - Toe out˚:*
Degrees
R - Toe out˚:*
Degrees
L - Finished Footplate Length:*
Decimal value optional
R - Finished Footplate Length:*
Decimal value optional

METAL/HYBRID AFO

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.

Yes
Who would you like a call from?*

Modifications (Modifier)Design options on device (Fab Supervisor)Shipping/Billing (Customer Support)
Technical Consult Team:
Notes:

0/250
Image upload (Optional):

Allowed Image types: jpg, jpeg, png, gif
Cancelof
Bilateral
- F0036
- F2600
- F0051
- F2840
- F2850
- F2830
- F2860
- F2820
- F1915
- F0046
- F0040
- F0040
- F0028
- F3310
- F0046
- F0046
- F0047
- F0052
- F0053
- F0023
- F5692
- F5692
- F0050
- F0050
- P1000
Raven Component Codes:
Lock Type:
Stirrup:
Ankle Joints:
Bars:
Posterior Stop:
- P9000
Should be Empty:

METAL/HYBRID AFO

METAL/HYBRID AFO

Device Design:

METAL/HYBRID AFO

Intrinsic Heel Skive requires external posting/wedging.

Joints/Uprights:

Ankle Joints

Bar:

Plastic

Special Order Transfer Papers can increase device turnaround time.

METAL/HYBRID AFO