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KAFO/KO Order Form

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PATIENT INFORMATION:
* = Required
Patient's Name:*		Sex: Male Female	Affected Side: Left Right Bilateral
Patient ID#		Age:	Height:	Weight:
Today's Date:		Due Date:
Account #		P.O. #
Facility:*		Practitioner:*
Bill to:*
Ship to:*
	Ground 2 Day Next Day

ORDER DESCRIPTION:

1. DEVICE:

N/A

KAFO KO	Cast ready to be poured? Yes No	Return Casts? Yes No
Ankle Set In:	Knee Set In:

Knee Joints Part #:	Other Info:

2.MODIFICATIONS & TRIMS:

N/A

Modification: Minimal Standard Tone Reducing	AFO Section Trimlines: Flex Rigid Semi-Rigid Solid	Ankle Joints: Tamarack Gillette Oklahoma Gafney Other:	Ankle Motion: Solid Free 90 Degrees

Foot Plate: Full Metatarsal Sulcus NYU/UCB	Proximal Flare? Yes No	Calf Flare? Yes No	Dorsal Flaps? Yes No

Forefoot Trim: Extend Laterally Extend Both Extend Medially Full Forefoot Wrap	Sabolich: Lateral Medial	Heel Wedge: Lateral Medial Full None	Heel Height:

3. MATERIAL

N/A

Plastic:
PolyPro
CoPoly
PolyEth
LLDPE(MODPE)

Plastic Color:
White
Black
Flesh
Brown
Other
Transfer Description

Thickness:
1/8
3/16
5/32
1/4

Tongue:
Yes
No

Tongue Type:
Calf
Thigh

Thickness:

Material:

4. Padding

N/A

Padding:
Naviculars
Heel
Pad After Pull
Pad Before Pull
Malleoli
Full Foot
No Padding

Padding Material:

Thickness:

Lining:
Yes
No

Lining Type:
Calf
Thigh

Thickness:

Material:

5. Finishing:

N/A

Knee Joints: Sandblasted Underplastic Over Plastic Polished Powder Coated Powder Coating Color	Ball Retainers: Yes No	Straps: Dacron Back Leather Back Pad Straps Hook & Loop Only No Straps	Patella Strap::
			Infra:
			Supra:
			Full Knee Cap:

ADDITIONAL INSTRUCTIONS :

Length:
Inches
Centimeters

Med Height	1.
Prox Thigh	2.
Mid Thigh	3.
Distal Thigh	4.
Knee Center	5.
Fib Head	6.
Widest Calf	7.
Mid Calf	8.
Above Ankle	9.
Ankle	10.
Lat Height	11.
	12.
	13.
	14.
	15.
	16.
Degree Toe Out	17.
Width at Met. Heads	18.
Heel to Sulcus	19.
Heel to Toe	20.

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KAFO/KO Order Form

PATIENT INFORMATION:

ORDER DESCRIPTION:

1. DEVICE:

2.MODIFICATIONS & TRIMS:

3. MATERIAL

4. Padding

5. Finishing:

ADDITIONAL INSTRUCTIONS :