Toll Free: 866.914.AOPS

Leather Gauntlet/Crow 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

LEATHER ANKLE GAUNTLET ORDER DESCRIPTION:

1. DEVICE:

N/A

Style:

Alpha

Wrap Around with Cut
Outs Copoly 3/32"

Beta

Posterior Support Malleolli
Poly Pro 5/32"

Gamma

Leather with Plastic Extension
Poly Pro 3/16"

Delta

Articulated

2. MATERIALS:

N/A

Closure:
Velcro
Laces
Speed Lace Proximal
Combination (lace distal/velcro proximal)

Plastic:
Seaflex 200
Seaflex 300
Copoly
Poly Pro

Color:
1. Sand
2. Dr. Taupe
3. Chestnut Brown
4. Black
5. Lt. Taupe
6. Discontinued
7. Russet Brown

3. PATIENT MODIFICATIONS

N/A

Range of Motion:
Leave Cast As Is
Correct to Neutral
Other:

Forefoot:
Leave as in Cast
Correct to Neutral

Foot Plate:
Full Foot Plate
Sulcus Foot Plate

Knee:
Knee affects leg angle
Genu Varum:

Genu Valgum:

Footboard:
Mold was taken using a footboard

Height of board:

CROW ORDER DESCRIPTION:

1. DEVICE:

N/A

Cast Ready to Be Poured: Yes No

Ankle Set In:

Charcot Restraint Orthotic Walker:

Copoly construction w/reinforced ankles
Fully lined with aliplast, 1/8'' PPT trapped under sole
Additional aliplast pad over instep before aliplast anterior shell is formed
Removable 1/4'' molded plastazole insole
Four dacron reinforced straps: top calf, distal calf, 45° at ankle, over forefoot
Firm crepe sole with rocker bottom

2. DESIGN:

N/A

Design Details:
Modification:

Foot Length:

Standard modification is to add 1'' to above

Color:

Extra Insole:
Yes No

Fracture Socks:
Yes No

Quantity:
Size:

ADDITIONAL INSTRUCTIONS :

Return Casts

Length:
Inches
Centimeters

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Metatarsal ML:

ANKLE:
Varus
Fexible
Valgus
Rigid
Degrees:

Toe In
Toe Out

Degrees:

Heel Height:

Foot Length:

Device Toe Plate Length:

Leather Gauntlet/Crow Order Form

PATIENT INFORMATION:

LEATHER ANKLE GAUNTLET ORDER DESCRIPTION:

1. DEVICE:

2. MATERIALS:

3. PATIENT MODIFICATIONS

CROW ORDER DESCRIPTION:

1. DEVICE:

2. DESIGN:

ADDITIONAL INSTRUCTIONS :