Thank you!© 2020 Cascade Dafo, Inc. All rights reserved. 25

Cascade Dafo, Inc.1360 Sunset Ave, Ferndale, WA 98248ph 800.848.7332 fax 855.543.0092

intl +1 360 543 9306 www.cascadedafo.com

Pat

ient

Last name:

First: c Male c Female

Date cast: / / c  N   c  W

Birth date: / / c Bilateral c Left only c Right only

Pra

ctit

ione

r

Name: Title:

Facility:

Street address:

City: State: Zip:

Email: Phone:

Bill

ing

c Cascade P&O is billing the patient’s insurance. –OR–

—UCAN No :

c Billing info is the same as practitioner facility. –OR–

c Billing facility:

Street address:

City: State: Zip:

P.O. No :

Shi

ppin

g

c Shipping info is the same as practitioner facility. –OR–

Shipping contact name:

Street address:

City: State: Zip:

Construction • Features • Options

Bottom Stabilization

c None—Standard NOTE: Varus or valgus forefoot alignments will receive stabiliza-tion on bottom of brace to support posted (raised) region.c Heel -OR- c Midfoot -OR- c Both

c Entire bottom stabilized with foam sole

c Entire bottom stabilized with foam sole and non-skid cover

c DFc PF

DAFO® 5Maximum control foot orthosis

Order 5 Rev.15 (Apr 2020)

Construction • Features • Options

MEDIAL (Left) LATERAL (Left)

Padding

FOAMPLASTIC TRIMMED PROXIMAL TO 1ST MET. HEAD, DISTAL TO 5TH

PLASTIC TRIMMED DISTAL TO TOES

Length

Plastic trimmed proximal to 1st met. head, distal to 5th

Foam extension attached

Toe Shelf

c Very Flexible Standard c Full length plastic

MEDIAL (Left) LATERAL (Left)

Padding

FOAMPLASTIC TRIMMED PROXIMAL TO 1ST MET. HEAD, DISTAL TO 5TH

PLASTIC TRIMMED DISTAL TO TOES

Length

Plastic trimmed proximal to 1st met. head, distal to 5th

Foam extension attached

Finished Brace AnglesHINDFOOT ALIGNMENT

c Correct to vertical (if misaligned) c Do not correct

FOREFOOT ALIGNMENT NOTE:�����������������

Choose forefoot alignment. Write posting height if needed—in. or mm.

RIG

HT

RIG

HT

RIG

HT

LEFT

LEFT

LEFT

Valgus

cVarus

cNeutral

cNeutral

cVarus

cValgus

c

(Cast alignment OK)

NOTE: If you don’t choose an option, you will receive the Standard.

OuterFrame: c Co-Poly Standard c Polyethylene

Padding: Shaded areas above are Standard

c Add extra navicular padding (boney pronators only)

Padding Color: c White

Standard c Other:

Rush orc c Rush order (adds $20)

Special Instructions

Bottom Stabilization

cMidfoot & Medial Heel—StandardNOTE: Varus or valgus forefoot alignments will receive stabiliza-tion on bottom of brace to support posted (raised) region.

cHeel -OR- cMidfoot -OR- c Both

c Entire bottom stabilized with foam sole

cNone

TransferPattern:

(Additional cost per brace) c No Transfer Standard

c Pattern: _______________________________ c ProvideOwn Pattern

(Transfer Pattern is not an option)

NOTE: Neutral forefoot alignments will not see foam on toe shelf.