Toll Free: 866.914.AOPS

KAFO/KO Order Form

PATIENT INFORMATION:
* = Required
Patient's Name:*		Sex: Male Female	Affected Side: Left Right Bilateral
Patient ID#		Age:	Height:	Weight:
Today's Date:		Due Date:
Account #		P.O. #
Facility:*		Practitioner:*
Bill to:*
Ship to:*
	Ground 2 Day Next Day

1. DEVICE:

N/A

N/A

Modification: Minimal Standard Tone Reducing	AFO Section Trimlines: Flex Rigid Semi-Rigid Solid	Ankle Joints: Tamarack Gillette Oklahoma Gafney Other:	Ankle Motion: Solid Free 90 Degrees

Foot Plate: Full Metatarsal Sulcus NYU/UCB	Proximal Flare? Yes No	Calf Flare? Yes No	Dorsal Flaps? Yes No

Forefoot Trim: Extend Laterally Extend Both Extend Medially Full Forefoot Wrap	Sabolich: Lateral Medial	Heel Wedge: Lateral Medial Full None	Heel Height:

N/A

Plastic:
PolyPro
CoPoly
PolyEth
LLDPE(MODPE)

Plastic Color:
White
Black
Flesh
Brown
Other
Transfer Description

Thickness:
1/8
3/16
5/32
1/4

Tongue:
Yes
No

Tongue Type:
Calf
Thigh

Thickness:

Material:

N/A

Padding:
Naviculars
Heel
Pad After Pull
Pad Before Pull
Malleoli
Full Foot
No Padding

Padding Material:

Thickness:

Lining:
Yes
No

Lining Type:
Calf
Thigh

Thickness:

Material:

N/A

Knee Joints: Sandblasted Underplastic Over Plastic Polished Powder Coated Powder Coating Color	Ball Retainers: Yes No	Straps: Dacron Back Leather Back Pad Straps Hook & Loop Only No Straps	Patella Strap::
			Infra:
			Supra:
			Full Knee Cap:

Length:
Inches
Centimeters