Patient Information First Name Last 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 # Product Info Small Height = 14" (35.5cm) Foot Length = 10" (25.5cm) Large Height = 16" (40.6cm) Foot Length = 11 3/8" (29cm) Device Selection Side Size Qty Left Small Large Right Small Large Additional Accessories Qty Valgus Control Strap Kit Method Tibial Strap Kit 6 Month Maintenance Kit 12 Month Maintenance Kit Small Method Pad Kit Large Method Pad Kit Optional Custom Foot Orthotic None Side Qty Left Right Pair Cast / Scan Upload From Cast or Foam Box 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/foam box 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 ° Submit
