Embed Size (px)
Citation preview
MATERIALS 5/32” Co-poly 3/16” Co-Poly 3/16” Poly Pro 1/4” Poly Pro 1/8” Profl ex (inner boot) 3/16” Pro-comp** 1/4” Pro-comp** Color: White Black
FOOT PLATE LENGTH Full Sulcus 3/4”
ADDITIONS (**Additional fabrication charge) Ankle Reinforcement** Tamarack Ankle JTS 90 degree Posterior Stop** Oklahoma Ankle JTS Adjusted Posterior Stop** Dorsi Assist Tamarack Ankle JTS Free motion Pad Tibial Shell** Pad Footplate** Transfer Paper** ALL Dacron Straps**
1570 Beam Avenue, Ste. 100, Maplewood, MN 55109 | p: 1-855-4TILTEC (484-5832) | f: 651-748-4574 | e: [email protected] | w: www.tillgestechnologies.com ©2018 Tillges Technologies. All rights reserved
FABRICATION INSTRUCTIONS TYPE OF AFO/KAFO Supra-Malleolar Masterfl ex Masterfl ex AFO Leather Ankle Gauntlet Leaf Spring AFO Solid Ankle AFO Convertible AFO Low Profi le Articulated AFO Articulated AFO Unloader AFO Partial Foot Pro-comp EZ Masterfl ex KAFO (specify knee joints) CAST CORRECTIONS
Leave as casted Correct to 90 degrees in shoe** HEEL POSTING Medial Post Lateral Post Neutral Post Heel Cut-out ENCOMPASSING 1st Metatarsal 5th Metatarsal ANKLE STRAPPING Standard Dynamic Layover No Strap ANKLE STRAP POSITION Valgus control Varus control
Customer ID: Order Date: Date Needed: PO#:
BILLING INFORMATIONFacility: Contact Name:
Address: City: State: Zip:
Phone: Fax: Email:
SHIPPING INFORMATION Same as BillingFacility: Contact: Cell #:
Address: City: State: Zip:
Phone: Fax: Email:
SHIPPING INSTRUCTIONS Next Day Air 2nd Day Air 3rd Day Air Ground Local / Hand Delivery
PATIENT INFORMATIONLast Name: First Name:
Male Female Age: Weight: Height: LT RT BIL
Diagnosis:
Special Instructions:
v5 09/2018
LAB USE ONLY Intake Date Tracking Number Modifi ed Date Technician Shipped Date
3/4 Foot Plate SulcusFull
CUSTOM AFO / KAFO ORDER FORM
MEASUREMENT / CASTING INFORMATION
Finished KAFO height
Fibular heightFinished AFO height
MTP height
