Bill To: Patient Name:

Address: Height: Left Male Weight: Right Female

Ship To: Age: Bilateral Address:

Practitioner:

Phone #:

OPS invoice / NG encounter:Date of Service:In-Office Request Date: am pm

Ankle stabilizer NL_2016_R1

Workorder #: (Lab Use Only)

Ankle Stabilizers

SURE-01 Standard

SURE-02 Pro Custom

SURE- 03 Dynamic Assist

SURE-08

Separate Uprights (Option)

Variable ROM

Custom lowerPre Fab upper

SURE-18 Lite

Please indicate any areas of concern.

Widest Calf

Mid Calf

Above Ankle

Ankle

Width at Met. Heads

Comments:

SURE-19 Stabilizer

From Heel to Finished Trim

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Separate uprights

Custom to castConnected Uprights

Separate Uprights (Option)

Custom to castConnected Uprights

Custom to castConnected Uprights

Separate Uprights (Option)

Custom to cast Custom to cast

Please ship cast and completed order form to: National Lab-Orlando 9561 Satellite Boulevard, Suite 350 Orlando, FL 32837 P (407) 852-6170 F (866) 855-1486 NationalLabs_Orlando@spsco.com

Plantarflexion

Hindfoot Subtalar Alignment

Neutral

Do Not Correct

Forefoot Alignment

Neutral

Do Not Correct

Other

Top Cover

Standard

Spenco Diabetic

Poron

Foot Plate Length

Standard (prox to met heads) Sulcus End of Toes

(weight bearing tracing required)

Heel cup

35 mm – Standard

18 mm

14 mm

Other ___

Joint Option

Full Flexion

Temporary Fixed

Permanent Fixed

90oDynamic Assist

Dorsi Assis Tamarackt

CAST ASSESSMENT AND MODIFICATIONS

Flexible

Addons

Heel Lift_________mm

Scaphoid (Medial) Sling

Cuboid (Lateral) Sling

Instep Strap

Foot Plate Accommodation

Navicular

Styloid

Medial Fascial Band

Other: _____________

Trimline

Forefoot Posting

Zero

Varus Degrees

Valgus Degrees

Arch Fill

Minimum – snug fit, no forgiveness

Standard – close conformity

Maximum – very forgiving

Top Cover Length

Metatarsals

Sulcus

Toes

Foot Orthosis width

Standard

Narrow

Low Profile Podiatric Trim

Medial Heel Skive 2º 4º 6º

Ankle Alignment

Neutral

Do Not Correct

Dorsiflexion ______o

*

*

* *

* *

* * *

* *

Additional charges may apply*

Other

ANKLE STABILIZER STANDARDS

SURE-01, 02, 03, 08 Foot plate cover: EVA Foot plate length: Proximal to met heads Heel cup: 35mm

SURE-18, 19 Padded soft covering Foot plate length: Proximal to met heads Heel cup: Custom to cast provided

Rigid/Fused

Comments:

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Foot/Ankle Condition

Hindfoot Posting

Degrees Zero

Varus

Valgus Degrees

Medial distal extension

Lateral distal extension (Use with abducted forefoot. Do not use with lateral ankle instability)