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Orthotic Order Form for Practitioners

This document is an order form for a rear entry ankle-foot orthosis (DAFO) from Cascade Dafo, Inc. It requests information about the patient such as name, date of birth, practitioner, and billing details. It also allows selection of options for the DAFO design including height, padding, strap color, foot alignment, and special instructions. The DAFO is constructed of polyethylene with options for an inner liner. Additional details like shipping address, corrections, and position of function can be specified.

Uploaded by

Summit Gautam
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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54 views1 page

Orthotic Order Form for Practitioners

This document is an order form for a rear entry ankle-foot orthosis (DAFO) from Cascade Dafo, Inc. It requests information about the patient such as name, date of birth, practitioner, and billing details. It also allows selection of options for the DAFO design including height, padding, strap color, foot alignment, and special instructions. The DAFO is constructed of polyethylene with options for an inner liner. Additional details like shipping address, corrections, and position of function can be specified.

Uploaded by

Summit Gautam
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Clear Form Data

Cascade Dafo, Inc.


1360 Sunset Ave, Ferndale, WA 98248
ph 800.848.7332
800-848-7332 intl +00 1 360 543 9306
fax 877.856.2160
877-856-2160 www.cascadedafo.com

Rear entry, DF block

Construction Features Options

c Male c Female

First:

//
//

Date cast:
Birth date:

cN

Footplate size:

MEDIAL (Left)

LATERAL (Left)

W
c
Padding

c Bilateral c Left only c Right only

Name:

Title:

Outer
Frame

Instep Strap

Facility:

Height

Patient

Last name:

Practitioner

Floor Reaction

DAFO

TO ORDER 1) SAVE to desktop 2) Fill in eForm 3) Print and send with the patient's cast to Cascade

Polyethylyne
Inner Liner

Street address:

City:

State:

Zip:

Email:

Phone:

Length
NOTE: If you dont choose an option, you will receive the Standard.

c Cascade P&O is billing the patients insurance. OR

Anterior
Height:

UCAN N :
Billing

c Specify:

Cast height must be greater than brace height

c Billing info is the same as practitioner facility. OR

1
c Option
Standard

c Billing facility:
Street address:
City:

State:

Zip:

P.O. No :

c Shipping info is the same as practitioner facility.OR


Shipping

of leg length
Standard

Shipping contact name:

City:

State:

Padding

Polyethylene
Inner Liner

Polyethylene
Inner Liner

c Correct to 34 DF c Correct to

c Do not correct

FOREFOOT ALIGNMENT

c Do not correct

(see drawing)

White
Standard
No pattern
Standard

Other:

Other:

No Transfer Standard

Pattern: _______________________________

NOTE: Drawings show finished orthosis.

Flexible

Medial

no containment

Standard

containment:

Neutral

Neutral

LEFT

LEFT

LEFT

RIGHT

RIGHT

RIGHT

AND / OR

Varus

Varus

Other:

Provide
Own Pattern

Inner Liner:

Choose forefoot alignment. Write posting height if neededin. or cm.

Valgus

(Outer frame only; additional cost per brace)

(Cast alignment OK)

HINDFOOT ALIGNMENT

c Correct to vertical (if misaligned)

Transfer
Pattern:

ANKLE ALIGNMENT (DorsiflexionPlantarflexion)


c DF
c PF

White
Standard

Standard

Instep Strap
Pattern:

Cast Correction Position of Function

Padding

Add navicular padding (boney pronators only)

Straps:
Strap
Color:

Zip:

c Option 3 (No Liner)

Padding

Padding Color:

Street address:

c Option 2

Lateral
containment:
Valgus

Soft foam (flexible)

Plastic

Soft foam (flexible)

Plastic

Special Instructions

Bottom Stabilization

c NoneStandard
c Heel

NOTE: Varus or valgus forefoot


alignments will receive stabilization
on bottom of brace to support
posted (raised) region.

c Rush order (adds $25)


2016 Cascade Dafo, Inc. All rights reserved.

30

Thank you!

Order Floor Reaction Rev.09 (May 2016)

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