Thermoplastic AFOs Compliance Documentation Packet | Page 6

TM

Arizona AFO ( 877 ) 780-8382 SafeStep ( 866 ) 712-7837

Thermoplastic AFO Collection

� Thermoplastic AFO Color : � Black � White Trim Line : � PLS � Semi-Solid � Solid Plastic Type : � Polypropylene 1 / 8 3 / 16 1 / 4

� Co-Polymer 1 / 8 3 / 16 1 / 4

� Thermoplastic AFO - Articulated Color : � Black � White Hinge : � Tamarack � Oklahoma � Camber Axis Tamarack Dorsi - Assist : Durometer - � 75 � 85 Plantar Stops : � 90 ° stop , plastic buttress

� Adjustable Stop

� Posterior Spring Assist Plastic Type : � Polypropylene 1 / 8 3 / 16 1 / 4

� Co-Polymer 1 / 8 3 / 16 1 / 4

� Supra Malleolar Orthosis Color : � Black � White

� Split Upright Color : � Black Hinge : � Tamarack � Oklahoma � Camber Axis Tamarack Dorsi - Assist : Durometer - � 75 � 85

� AZ CROW Walker™ Color : � Black � White

Ship to address : 4825 East Ingram St . Mesa , AZ 85205 Fax : 480.222.1599

Patient Information :

TAC170913

Dispense Date : _____________________ Work Order #:

Measurements - please include for optimal fi t : Indicate Location

Diameters for Ulcer Reliefs

� Right Foot � Left Foot � Bilateral Patient Name : _________________________________________ Height : ______ Weight : ______ Shoe Size : _____ Gender : � M � F Dx : _____________________ D . O . B : ____________________

Shipping and Billing Information : Bill to my account :

� Arizona � SafeStep Account # _______________

Practitioner : Email : PO #:

________________________________________ ________________________________________ ________________________________________ Facility Name : ________________________________________ Phone : Fax :

Lenghts

Circumference

Distal Tibia

Forefoot - ML Ankle - ML

_________________________________________

________________________________________ Ship to address : ________________________________________ Bill to address : ________________________________________

Shipping Options :

� Ground � 3 Day Air � 2 Day Air � Overnight

Brace Height

Special Instructions : If you do not want the dorsi-plantar angle of the cast set to our recommendations , please choose :

� Leave cast exactly as is � Correct Ankle Varus / Valgus

90 °

Widest Calf

� Correct Forefoot to Neutral

� Other __________________

Additions : � Carbon Ankle Inserts � Full Toe Plate

� Foam lining : Plastazote 1 / 8 3 / 16 � Foam lining : Aliplast 1 / 8 3 / 16

Remarks : ____________________________________________ _____________________________________________________ ____________________________________________________