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  • StrideLogic Care Fabrication Form

    Intake Information

  • Please do not print the Review page.

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

  • Format: (000) 000-0000.

  • Please ensure your email is entered all in lowercase. Only approved clinicians can complete this form. 

    • Patient Information: 
    • Bilateral:*
    • Bilateral Type:*
    • Affected Side:*

    • Bilateral Symmetrical: 

      • Left and Right sides can have different Alignment, Trimlines
      • Same Design and Finishing options
    • Scan being submitted with order:

    • Submission Type:

      • Fiberglass Cast: Negative

        Please include a printed Work Order with the cast when shipping.
    • Raven Base Code:

  • StrideLogic Care Fabrication Form

    Configurator
    • Design: 


    • Bench Alignment Standards

      StabilizerBase (Stabilizer: +1)

      StabilizerBase+ (Lil-Buddy: +5)

      ActivatorCore (Go-Buddy: +3)

      MobilizerCore (Lil-Mobilizer: +3)

      ActivatorMax (Big-Buddy: +1)

      TransformerMax (Transformer: +2)

      MobilizerMax (Mobilizer: +1)

      EnergizerMax (Super Strut: +1)

    • Image field 1284
    • Alignment 
    • Left - Ankle Alignment:*
    • Right Ankle Alignment:*

    • Final Left Ankle Position:

    • Final Right Ankle Position:

    • Set the Left Ankle in   *   ° of      *        

    • Set the Right Ankle in   *   ° of      *        

    • Left - Forefoot Alignment:*
    • Right - Forefoot Alignment:*

    • Final Left Forefoot Position:

    • Set the Left Forefoot in   *   ° of      *        

    • Final Right Forefoot Position:

    • Set the Right Forefoot in   *   ° of      *        

    • Left - Hindfoot Alignment*
    • Right - Hindfoot Alignment*
    • Left - Abduction/Adduction:*
    • Right - Abduction/Adduction:*
    • Left - Hight Dorsal Peak:*
    • Right - Hight Dorsal Peak:*
    • Heel Post Needed:*
    • Trimlines 
    • Are your forefoot trimlines symmetrical?*
    • Are your marked mold heights symmetrical?*
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    • Thermoforming: 
    • Outer Boot Transfer:
    • Inner Boot Transfer:
    • 0/250
    • Design Finishing: 
    • Strap Length:*
    • Strap Color:*
    • Strap Pad Color:*
    • Calf Section Trimlines:*
    • Wheelchair Trimline Needed:*
    • Anterior Shell Length:*
    • Shoe Width:*
    • Shoe Model:*
    • Shoe Color:*
    • Shoe Color - 1st Choice:*
    • Shoe Color - 2nd Choice:*
    • 0/250
    • Today's Date:*
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  • StrideLogic Care Fabrication Form

    Shipping
  • Browse Files
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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:*
     - -

  • {requestedInoffice}{requestedInoffice1172}{requestedInoffice1173}{requestedInoffice1174}

    • Requested In-Office Date: 
    • Image field 1270
  • Should be Empty: