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    KAFO/KO Order Form: 8647 W. 95th Street Hickory Hills, IL 60457 (T) 866.914.AOPS (T) 708.237.4099 (F) 708.598.285 7

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    Salem
    1. This document is an order form for a Knee-Ankle-Foot Orthosis (KAFO) or Knee Orthosis (KO) from a medical supply company. It requests patient information, specifications for the orthotic device including modifications, materials, and additional instructions. 2. The form collects details about the patient, device ordered, modifications needed, material selections, padding requirements, and any special instructions for fabrication. 3. Payment and shipping information is also requested to complete the order.

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    KAFO/KO Order Form: 8647 W. 95th Street Hickory Hills, IL 60457 (T) 866.914.AOPS (T) 708.237.4099 (F) 708.598.285 7

    Uploaded by

    Salem
    61 views1 page
    1. This document is an order form for a Knee-Ankle-Foot Orthosis (KAFO) or Knee Orthosis (KO) from a medical supply company. It requests patient information, specifications for the orthotic device including modifications, materials, and additional instructions. 2. The form collects details about the patient, device ordered, modifications needed, material selections, padding requirements, and any special instructions for fabrication. 3. Payment and shipping information is also requested to complete the order.

    Original Description:

    kafo

    Original Title

    KAFO_KO_Form 1.1

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    © © All Rights Reserved

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    1. This document is an order form for a Knee-Ankle-Foot Orthosis (KAFO) or Knee Orthosis (KO) from a medical supply company. It requests patient information, specifications for the orthotic device including modifications, materials, and additional instructions. 2. The form collects details about the patient, device ordered, modifications needed, material selections, padding requirements, and any special instructions for fabrication. 3. Payment and shipping information is also requested to complete the order.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    61 views1 page

    KAFO/KO Order Form: 8647 W. 95th Street Hickory Hills, IL 60457 (T) 866.914.AOPS (T) 708.237.4099 (F) 708.598.285 7

    Uploaded by

    Salem
    1. This document is an order form for a Knee-Ankle-Foot Orthosis (KAFO) or Knee Orthosis (KO) from a medical supply company. It requests patient information, specifications for the orthotic device including modifications, materials, and additional instructions. 2. The form collects details about the patient, device ordered, modifications needed, material selections, padding requirements, and any special instructions for fabrication. 3. Payment and shipping information is also requested to complete the order.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    KAFO/KO Order Form

    8647 W. 95th Street • Hickory Hills, IL 60457 • ( T ) 866.914.AOPS • ( T ) 708.237.4099 • ( F) 708.598.285 7


    (2677)

    PA T I E N T I N F OR MAT I ON

    Today’s Date: Due Date: Account #: P.O. #:

    Patient Name: Facility: Practitioner:

    Patient ID #: Bill To: Ship To:

    Sex: ■ M ■ F Affected Side: ■ Left ■ Right ■ Bilateral

    Age: Height: Weight: ■ Ground ■ 2 Day ■ Next Day

    ORDER DESCRIPTION

    1 Device: ■ N/A Heel Wedge: 5 Finishing: ■ N/A


    ■ Lateral ■ Full
    ■ KAFO ■ KO Knee Joints:
    ■ Medial ■ None
    Cast: ■ Sandblasted ■ Polished
    Heel Height: ■ Powder Coated Color:
    Ready to Be Poured? ■ Yes ■ No
    ■ Underplastic ■ Overplastic
    Return Casts? ■ Yes ■ No 3 Material: ■ N/A
    Ankle Set In:
    ˚ Plastic:
    Ball Retainers:
    Knee Set In:
    ˚ ■ Yes ■ No
    Knee Joints Part #: ■ Poly Pro ■ PolyEth
    Straps:
    Other Info: ■ CoPoly ■ LLDPE (MODPE)
    ■ Dacron Back ■ Hook & Loop Only
    Plastic Color:
    ■ Leather Back ■ No Straps
    2 Modifications & Trims: ■ N/A ■ White ■ Flesh ■ Pad Straps
    Modification: ■ Black ■ Brown Infra: Supra:
    ■ Minimal ■ Standard ■ Other: Patella Strap:
    ■ Tone Reducing ■ Transfer Description: Full Knee Cap:

    AFO Section Trimlines: Thickness:


    If a discrpancy exists, go by: ■ Impression
    ■ Flex ■ Semi-Rigid ■ 1/8 ■ 5/32
    ■ Measurements
    ■ Rigid ■ Solid ■ 3/16 ■ 1/4 L AT H E I G H T
    MED HEIGHT
    Ankle Joints: Tongue:
    PROX THIGH
    ■ Tamarack ■ Oklahoma ■ Yes ■ Calf
    ■ Gillette ■ Gafney ■ No ■ Thigh MID THIGH

    ■ Other: Thickness: D I S TA L T H I G H
    Material:
    Ankle Motion: KNEE CENTER
    ■ Solid ■ 90˚ 4 Padding: ■ N/A FIB HEAD
    ■ Free
    Padding: WIDEST CALF
    Foot Plate:
    ■ Naviculars ■ Malleoli MID CALF
    ■ Full ■ Sulcus
    ■ Heel ■ Full Foot
    ■ Metatarsal ■ NYU/ UCB ABOVE ANKLE
    ■ Pad After Pull ■ No Padding
    ANKLE
    Proximal Flare: ■ Pad Before Pull
    ■ Yes ■ No Padding Material:
    Calf Flare: Thickness:
    Degree Toe Out:
    ■ Yes ■ No Lining:

    Dorsal Flaps: ■ Yes ■ Calf


    ■ Yes ■ No ■ No ■ Thigh
    HEEL TO SULCUS
    Lining Material:
    Forefoot Trim:
    Thickness:
    ■ Extend Laterally ■ Extend Medially W I D T H AT
    M E T. H E A D S
    ■ Extend Both ■ Full Forefoot Wrap TO TOE

    Sabolich: Additional Instructions:


    ■ Lateral ■ Medial

    2014.11_1.1

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