Thank you!© 2019 Cascade Dafo, Inc. All rights reserved. 60

Cascade Dafo, Inc.1360 Sunset Ave, Ferndale, WA 98248ph 800.848.7332 intl +00 1 360 543 9306fax 855.543.0092 www.cascadedafo.com

Pat

ient

Last name:

First: c Male c Female

Date cast: / / c  N   c  W

Birth date: / / c Bilateral c Left only c Right only

Pra

ctit

ione

r

Name: Title:

Facility:

Street address:

City: State: Zip: Email: Phone:

Bill

ing

c Cascade P&O is billing the patient’s insurance. –OR–

—UCAN No :

c Billing info is the same as practitioner facility. –OR–

c Billing facility:

Street address:

City: State: Zip:

P.O. No :

Shi

ppin

g

c Shipping info is the same as practitioner facility. –OR–

Shipping contact name:

Street address:

City: State: Zip:

Finished Brace AnglesANKLE ALIGNMENT (Dorsiflexion–Plantarflexion)

c Correct to 3–4° DF c Correct to ° c Do not correct

HINDFOOT ALIGNMENTc Correct to vertical (if misaligned) c Do not correct

FOREFOOT ALIGNMENT NOTE: Drawings show finished orthosis.

Choose forefoot alignment. Write posting height if needed—in. or mm.

RIG

HT

RIG

HT

RIG

HT

LEFT

LEFT

LEFT

Valgus

c

Varus

c

Neutral

cNeutral

cVarus

c

Valgus

c

c Rush order (adds $25)

Construction • Features • Options

(Cast alignment OK)

Bottom Stabilization

c None—Standard NOTE: Varus or valgus forefoot alignments will receive stabiliza-tion on bottom of brace to support posted (raised) region.c Heel -OR- c Midfoot -OR- c Both

c Entire bottom stabilized with foam sole

c Entire bottom stabilized with foam sole and non-skid cover

c DFc PF

Special Instructions

Toe Shelf—Inner Liner

cFlexible — no containment Standard

 c Medial

containment:

 c Lateral

containment:

AND / OR

PF resist, DF free, Softy liner

Order DAFO Softback Softy Rev.3 (April 2019)

NOTE: If you don’t choose an option, you will receive the Standard.

Liner: Softy foam (white only) Standard

c Add extra navicular padding (boney pronators only)

Instep & Forefoot Straps:

Standard (see drawing)

c Add toe abduction strap

StrapColor: c White

Standard c Other:

Instep Strap Pattern: c

No pattern Standard c Other:

MEDIAL (Left) LATERAL (Left)

Instep & Forefoot Straps

Proximal StrapLiner

TransferPattern:

(Additional cost per brace) c No Transfer Standard

c Pattern: _______________________________ c Provide Own Pattern

Softback™

DA

FO®

Special Instructions

Toe Shelf—Inner Liner

cFlexible — no containment Standard

c Medial

containment:

c Lateral

containment:

AND / OR

c Rush order (adds $25)