LOWER EXTREMITY ORTHOMETRY FORM
CUSTOMER NAME: ________________________________________
PATIENT NAME: __________________________________________
BILL TO / SHIP TO: _________________________________________
AGE: _______
ADDRESS:_________________________________________________
DIAGNOSIS: ______________________________________________
__________________________________________________________
DATE REQUIRED: ________________________________________
PHONE: ______________________FAX:________________________
PO# : _____________________________________________________
CONTACT: _______________________________________________
SHIPPING METHOD: _______________________________________
RIGHT LEG
HT: ________
BILATERAL
LEFT LEG
WT: ________ SEX: __________
TRIM LINES
*******PLEASE CORRECT YOUR CAST IF NECESSARY!!!!!!!!
PLS
SEMI
CORRECT CAST TO 90 DEGREES_______________________
ANKLE MOTION: FREE
LEAVE CAST AS IS: ____________
PLANTAR STOPS:
CORRECT ANKLE VARUS/VALGUS: _________________________
OTHER: ________________________________________________
REMARKS: _______________________________________________
Footplate: FULL FOOT
UCBL
SMO
CROW BOOT
AFO
HOOK & LOOP
AAFO
KAFO
COLOR: WHITE
COPPER RIVETS
PTB
MED/LAT TAB
90 STOP
OTHER
TC2
PLASTIC
ELITE
SULCUS
OR
DACRON BACKED
BLACK
SPEEDY RIVET
PRE-TIBIAL PAD: ALIPLAST (VELCRO)
MATERIALS
POLYPRO
COPOLY
THICKNESS: 1/8”
PE
5/32”
COLOR: NATURAL
LINER:
OTHER
3/16”
1/4”
BLACK
UNLINED
1/8”
3/16”
1/4”
OTHER PADDING (WHERE?) : __________________________________
ANKLE JOINTS
TAMARACK
APPALAC HIAN
OKLAHOMA
CAMBER AXIS
ADJUSTABLE
SLOTTED FELT
INSTEP STRAP
MEASUREMENTS
KNEE CENTER TO FLOOR: ____________
MEDIAL FINISHED HEIGHT: __________
LATERAL FINISHED HEIGHT:_____________
AFO HEIGHT:______________________
FULL FOOT LENGTH: ______________
___________________________________________________
___________________________________________________
KNEE JOINTS
DROP LOCK
SCREWS
SPECIAL INSTRUCTIONS [MODIFYING OR FINISHING] : _______
DORSI-ASSIST
INTEGRATED ANKLE
BAIL LOCK
PROX TO MTP
STRAPS
__________________________________________________________
ORTHOSIS DESIGN
SOLID
STEP LOCK
BALL RETAINERS
___________________________________________________
___________________________________________________
**CASTS WILL BE SAVED FOR 30 DAYS UNLESS OTHERWISE REQUESTED.
OTHER: _________________________________________________
PROFESSIONAL TECHNOLOGIES INTL, INC.
95 Ryan Drive, Unit 8
Raynham, MA 02767
TEL: 508-821-9600 TOLL FREE: 866-819-1157
FAX: 508-821-9609 TOLL FREE: 866-473-8105