Thermoplastic Order Form
PO#:
Diagnosis:
Phone: 800-521-2192 Fax: 248-588-4555 BeckerOrthopedic.com 574 Robbins Dr. Troy, MI 48083
Patient:
PATIENT INFORMATION
ORDER INFORMATION
Age: Sex: Height: Weight:
Facility:
Clinician:
Address:
City:
State/Province/Region:
Country:
Phone (Office):
Fax:Phone (Cell):
Zip:
PRACTIONER SHIPPING INFORMATION
Email:
Select Finished Alignment:
FOREFOOT ALIGNMENT (VARUS/VALGUS)
Toe Out:
Left:
Right:
Toe Out Angle:
Left Right
(+) Toe Out(-) Toe In
HKAFO REQUIREDANATOMIC MEASUREMENTS
Height Circumference ML
IliacCrest
HipCenter
Ischium Height
Patellar Tendon Height
(Required for ischial brim):
(Required for PTB):
DEVICE SELECTION
KAFO
AFO
HKAFO
LeftRight
Device Type:
Side:
CAST CORRECTION
Sagittal Ankle CorrectionAnkle Alignment (dorsiflexion/plantarflexion)
Do not correctCorrect to 4° DF*Correct to ° DF PF
Sagittal Knee Correction
Flexion Extension
Do not correctCorrect to Neutral*Correct to:
Varum Valgum
Coronal Knee CorrectionDo not correct*Correct to NeutralCorrect to:
Coronal Hindfoot AlignmentDo not correctCorrect to vertical*Correct to °
Varum Valgum
Ankle ML Knee ML
MEASUREMENTS
LateralHeight
MedialHeight
DistalThigh
KneeCenter
AFO Height
Left Right
Finished Height Measurements
Heel Height
Ankle ML Knee ML
Inches Centimeters
+
Right Left
Neutral* Neutral*Valgus Varus Varus Valgus
Ankle Joint AlignmentMechanical*Anatomical
Other:
Note: If you don’t choose an option, the * (default) option will be selected for you. AFO From Scan Orthometry Form required when providing scanned model.+
SHELL CONFIGURATION
SPECIAL INSTRUCTIONS
COMPONENT SELECTION
Medial Supramalleolar FlareLateral Supramalleolar FlareAnkle Corrugation
Ankle Control
Footplate LengthFull Foot Length*Sulcus Length
Full Control*Long Medial (Supination Control)Long Lateral (Pronation Control)Molded Inner Boot
Footplate Control
MaterialsPolypropylene*Copolymer
3/161/4
Thickness1/85/32
None*Medial Condylar ExtensionLateral Condylar Extension
Knee Control
Liners / Padding / InsertsNone*Extra Navicular PaddingFull FootplatePlantar FootplateCalf SectionThigh SectionAnkles
None*HeelForefootHeel Lift Height_______
Footplate Stabilization
TongueCalf SectionThigh Section
AccessoriesGrowth ExtensionsQuick Release
Ankle Joints (select one)
RigidSemi RigidPosterior Spring (PLS)
Solid Ankle
Dorsiflexion Assist (3225)Double Action (SLM2825)
Titanium (Extra Charge)
OklahomaHeavy Duty
Camber Axis
TamarackNeutralDorsi Assist ( Specify 75/85/95 )
Posterior StopFixed Plastic PF StopMotion Control Limiter for PF Only (Model 755)Motion Control Limiter for PF/DF (Model 655)
Other (Specify)
Standard ActionNo MotionStop MotionFree Motion
DF PF
Plastic ColorBlackWhite*
Transfer Options
Model # ________________
BeckerOrthopedic.com/Education/OrthometryForms
available at
StrapsStandard Straps with Pads*
Please check the appropriate box to select finish trimlines
Bar MaterialAluminumStainless Steel
Hip JointsFree MotionRing LockOther (Specify)
Knee Joints (select one)
Posterior OffsetAlignment
Free Motion
Other (Specify)
Ratchet Lock
Lever Lock
Ring LockBall Catch
Lock Type
Bail*BLISSHD Lever
Bail*BLISSHD Lever
Metal Joints (3025)
Thermoformable Joints
*
ShellsNone
Calf ThighInterlocking Polypropylene (custom)
TelescopingCalf Thigh