TMA INSERT AND AFO COMBO

  • Access Legacy PDF work order. Legacy form will be accepted until Mar 4th. 

  • Legacy form will no longer be accepted.

  • Please do not print the Review page.

    Scroll to the bottom, hit Complete and then download the work order. 

  • TMA INSERT AND AFO COMBO

    Intake Information
  • 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:
    • Scan being submitted with order: (Deprecated-Do Not Delete)*

    • 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.

  • TMA INSERT AND AFO COMBO

    Device Type

  • Design: Cork Base, Poron Inner, Plastazote Top Cover

  • Indication: Fixed/Painful Ankle

    Design: Mid-Calf, Copoly, Solid AFO, SMO, TMA insert

  • Indication: Compromised Skin, Equino-Varus, PF Contracture

    Design: Mid-Calf, Copoly, Articulated AFO, SMO, TMA Insert, Launchpad Joint and X

  • Raven Base Code:
  • Device Type:

  • TMA INSERT AND AFO COMBO

    Configurator
  • 0/250
    • Tuning: 
    • Tuning: Is this device being tuned?*

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

    • Foot on Casting block
    • Please indicate measurement unit:*
    • Tuning Ankle Alignment:*

    • Final Ankle Position (Ankle Angle):

    • Set the Ankle in   *   ° of      *       

    • Posting Type:*
    • Image field 1321
    • Image field 1322
    • Image field 1324
    • Toe Ramp:*
    • Image field 1316
    • Image field 1317
    • Image field 1318
    • Set Heel Wedge/Post To:*
    • Image field 874
    • Shoe Heel Height:*
    • External Post Attachment:*
    • Measurements: 
    • Go by:*
    • Please indicate measurement unit:*
    • Patient Measurements
    • Patient Measurements
    • Patient Measurements

    • Selected unit: {pleaseIndicate910}

    • Design/Requirements: 

    • All Requirements need to be met before you can proceed. 

    • Requirements:*
    • Requirements:*

  • TMA INSERT AND AFO COMBO

    Notes
  • Who would you like a call from?*
  • 0/250
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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:
     - -

  • Daily HFN Capacity

  • {requestedInoffice}{requestedInoffice1373}{requestedInoffice1374}{requestedInoffice1375}

    • Requested In-Office Date: 
    • Image field 1378

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

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