SAFO ORDER FORM SD 71 Rev 8
FOR DOC USE ONLY
DOC NO: WEEK NO: APPOINTMENT: COUNTRY:
[1] Patient Details
Name� Date of Birth�
Diagnosis�
[2] Orthotist Details
Orthotist� Purchase Order No� Date�
Company Address�
Contact Details� Tel No� E-mail�
[3] Product
Type� SAFO CLASSIC SAFO WALK SAFO SPORT
Colour� B1 B2 B3 B4 B5 B6 B7 Red Blue Yellow Other
[4] Product Details
Height� 24 cm
(standard adult male)
22 cm
(standard adult female) Other Required - Please specify
Product� Left SAFO Right SAFO Bi-Lateral
Heel Opening
Height� Standard: 65mm Other Please specify Closed Heel
SPECIAL
REQUIREMENTS�
(Please write in BLOCK CAPITALS)
SUPPORT� Reinforcement - 70 shore layup Standard (as shown) (If
different please indicate and mark clearly on pictures below)
* If you wish to extend the standard support drawn on the
anterior aspect of the diagrams below please amend accordingly (can
be extended further around the leg or
lower towards the plantar surface).
LEFT SAFO RIGHT SAFO
LATERAL SIDE MEDIAL SIDE LATERAL SIDE MEDIAL SIDE
Dorset Orthopaedic Company Ltd, Unit 11 Headlands Business Park,
Ringwood, Hampshire, BH24 3PB
Tel: 01425 483032 – [email protected]
[5] SAFO Measurements – Please fill in Orthotist boxes only,
greyed out boxes for DOC only
Measurement Top Circum. Above Malleoli Malleoli Short Heel
Instep Behind Met Heads
Met Heads
Left mm 1 2 3 4 5 6 7
Orthotist�
DOC Before
DOC After
Right mm 1 2 3 4 5 6 7
Orthotist�
DOC Before
DOC After
[6a] Cast Standard for SAFO Classic and SAFO Walk [6b] Cast
Standard for SAFO Sport
Angle of Cast Degree of angle cast taken ° Degree of angle cast
taken °
Standard cast should be taken with the foot in a 3-5°
dorsiflexion on
a flat surface if achievable.
Sport cast should be taken with the foot in a 90° dorsiflexion
on a
flat surface if achievable.
Reason if different - Reason if different -
(The min. height of a negative cast from heel to proximal edge
is 28cm) The cast must be to a B/K length.
All bony prominences MUST be marked with indelible pencil.
The cast should extend 2cm forward of the 1st
& 5th
Metatarsal joints.
All bony prominences MUST be marked with indelible pencil,
including the Tibial Tubicle.
Malleoli�
Met heads�
Dorsum of foot�
The cast should extend 2cm forward of the 1st
& 5th
Metatarsal joints.
PLEASE MAKE SURE YOU COMPLETE THE OTHER SIDE OF FORM
[7] Orthotist - I have read and agree to Dorset Orthopaedic
Terms & Conditions. I have filled out sections [1] to [6]
Name� Date�
Signature�
FOR DOC USE ONLY
CAST RECTIFICATION NOTES:
MANUFACTURING NOTES / DIAGRAMS
Technician
Name:
Inspector
Name:
Name: Date: Date:
Date:
DELIVERY
DATE:
COURIER / POSTAL INSTRUCTIONS
POSTAL YES / NO POSTAL CHARGE YES / NO
