Thank you!© 2020 Cascade Dafo, Inc. All rights reserved. 26
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:
Finished Brace AnglesANKLE ALIGNMENT (Dorsiflexion–Plantarflexion)
c Correct to 3–4° DF c Correct to ° c Do not correct
HINDFOOT ALIGNMENTc Correct to vertical (if misaligned) c Do not correct
FOREFOOT ALIGNMENT NOTE: Drawings show finished orthosis.
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
c Rush order (adds $20)
Construction • Features • Options
(Cast alignment OK)
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 Toe Shelf—Inner Liner
cFlexible — no containmentStandard
c Medial
containment:
c Lateral
containment:
AND / OR
Special Instructions
Order 8 Softy Rev.13 (Feb 2020)
Resting, non-ambulatory, Softy liner
8
Non-StretchAnterior Strap
Instep & Forefoot Straps
MEDIAL (Left) LATERAL (Left)
Hei
ght
Length
InnerLiner
OuterFrame
Padding
DA
FO®
NOTE: If you don’t choose an option, you will receive the Standard.
Posterior Height: c ⅔ to ¾ of leg length
Standard c Specify:
• Cast height must be greater than brace height •
InnerLiner:
c Softy foam (white only) Standard (outer frame extends to full-length)
c Polyethylene (outer frame trimmed at sulcus)
c Add extra navicular padding (boney pronators only)
Straps: Standard(see drawing) c Add toe abduction strap
StrapColor: c White
Standard c Other:
Instep Strap Pattern: c
No pattern Standard c Other:
Toe Rise and Cuff Padding Color:
c White Standard c Other: