Toll Free: 866.914.AOPS

Metal AFO/KAFO 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

1. DEVICE:

N/A

Metal AFO Meta KAFO Shoe Transfer	Tracing Reversed and Device Ready to be Fabricated: Yes No

N/A

Shoe Size	Rocker Sole: Toe Only Heel & Toe	Order Status: One Shoe Sent Pair of Shoes Sent Shoes Already on Order Shoes Need to be Ordered
Model #
Color

N/A

Sidebars: Single Double Aluminum Stainless Steel Sidebar size:	Joint Type: Double Action Limited Action Dorsi Assisi Free	Stirrup: Standard Split Reinforced Wide Tongue Long Tongue NYU/UCB	T-Strap: Lateral Medial Finishing: Extended Steel Shank Velcro to Shoes	Shoe Modifications:

N/A

Knee Joints Part #: Leather Color:

Knee Straps:
Full Knee Cap
Valgus Control
Suprapatellar
Varus Control
Intrapatellar
None

Finish:
Sandblasted
Polished

Ball Retainers:
Yes
No

Notes:

Inches
Centimeters

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