Patient Information Patient Name Age Height Ft/In. Cm. Weight lb kg Diagnosis Practitioner Shipping Information Facility Clinician Address City State / Province Zip / Postal Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua & BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia & HerzegovinaBotswanaBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (DRC)Cook IslandsCosta RicaCôte d’IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaEuropeFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong Kong SARHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKoreaKosovoKuwaitKyrgyzstanLaosLatin AmericaLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SARMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian AuthorityPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSamoaSan MarinoSão Tomé & PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSt Helena, Ascension, Tristan da CunhaSt. BarthélemySt. Kitts & NevisSt. LuciaSt. MartinSt. Pierre & MiquelonSt. Vincent & GrenadinesSudanSurinameSvalbard & Jan MayenSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTurks & Caicos IslandsTuvaluU.S. Outlying IslandsU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis & FutunaWorldYemenZambiaZimbabwe Phone Email Order Information PO # Account # Device Selection Single Upright Flat Footplate Left Right Include Custom Foot Orthotic Side Qty Left Right Pair Order Information From Cast Ship the cast with this completed order form to: Becker Orthopedic Central Fabrication 574 Robbins Dr. Troy, MI 48083 From Scan Type Scan of patient's leg or positive cast Scan of outside negative mold Mold Thickness in mm Up to 12 files can be uploaded. Accepted file types are .STL and .OBJ. Foot Orthotic Options Clear Functional Soft Medium Firm Extra Firm All Top covers in Black Puff 1/16" + 1/16" PPT Diabetic 40 Durometer All Top covers P-cell 1/8" + PPT 1/16" Toe Filler Include MetPad None Small Large Posting Clear Left Side Forefoot Medial ° Lateral ° Rearfoot Medial ° Lateral ° Right Side Forefoot Medial ° Lateral ° Rearfoot Medial ° Lateral ° Measurements Units Imperial (in) Metric (mm) Confirm that the patient's calf circumference is less than 40cm [16 inches] Confirm that the finished AFO height is between 34cm [13-1/2 inches] and 40cm [16 inches] Left Side Finished Height in Finished Height ML in Finished Height Circumference in Calf Apex Height in Calf Apex ML in Calf Apex Circumference in Proximal to Malleoli Height in Proximal to Malleoli ML in Proximal to Malleoli Circumference in Left Foot Length in Right Side Finished Height in Finished Height ML in Finished Height Circumference in Calf Apex Height in Calf Apex ML in Calf Apex Circumference in Proximal to Malleoli Height in Proximal to Malleoli ML in Proximal to Malleoli Circumference in Right Foot Length in Additional Accessories Valgus Control Strap Extra Method Tibial Strap Kit Triple Action 6-Month Maintenance Kit Triple Action 12-Month Maintenance Kit Submit
