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