Toll Free: 866.914.AOPS
Metal AFO/KAFO 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
ORDER DESCRIPTION:
1. DEVICE:
N/A
Metal AFO
Meta KAFO
Shoe Transfer
Tracing Reversed and Device Ready to be Fabricated:
Yes
No
2. SHOE(S):
N/A
Shoe Size
Rocker Sole:
Toe Only
Heel & Toe
Order Status:
One Shoe Sent
Pair of Shoes Sent
Shoes Already on Order
Shoes Need to be Ordered
Model #
Color
AFO
N/A
Sidebars:
Single
Double
Aluminum
Stainless Steel
Sidebar size:
Joint Type:
Double Action
Limited Action
Dorsi Assisi
Free
Stirrup:
Standard
Split
Reinforced
Wide Tongue
Long Tongue
NYU/UCB
T-Strap:
Lateral
Medial
Finishing:
Extended Steel Shank
Velcro to Shoes
Shoe Modifications:
KAFO
N/A
Knee Joints Part #:
Leather Color:
Knee Straps:
Full Knee Cap
Valgus Control
Suprapatellar
Varus Control
Intrapatellar
None
Finish:
Sandblasted
Polished
Ball Retainers:
Yes
No
Notes:
ADDITIONAL INSTRUCTIONS :
Inches
Centimeters
Circumference
Diameter
Length
A-Waist Line
1.
2.
3.
B-Pelvic Line
4.
5.
6.
C-Trochanter
7.
8.
9.
Ischial Tuberosity
12.
D-30 MM
10.
11.
15.
E
13.
14.
16.
F-Knee Axis
17.
18.
G
19.
20.
22.
Fib Neck
21.
H-Ankle Axis
24.
23.
