Thank you!© 2020 Cascade Dafo, Inc. All rights reserved. 30

Cascade Dafo, Inc.1360 Sunset Ave, Ferndale, WA 98248ph 800.848.7332 intl +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 $20)

Special Instructions

Toe Shelf

cFlexible — no containment Standard

Medial containment:

c Soft foam (flexible)

c Plastic

Lateral containment:

c Soft foam (flexible)

c Plastic

AND / OR

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

NOTE: Neutral forefoot alignments will not see foam on toe shelf

DAFO® FAFor smaller patients, fixed ankle, PF block, DF block

Order FA Rev.08 (Apr 2020)

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

Posterior Height: c ⅔ to ¾ of leg length

Standard c Specify:

• Cast height must be greater than brace height •

Padding: Shaded areas above are Standard

c Add extra navicular padding (boney pronators only)

Padding Color: c White

Standard c Other:

Straps: Standard(see drawing) c Add toe abduction strap

StrapColor: c White

Standard c Other:

Instep Strap Pattern: c

No pattern Standard c Other:

Hei

ght

Length

MEDIAL (Left) LATERAL (Left)

Instep & Forefoot Straps

Non-StretchAnterior Strap

Padding

TransferPattern:

(Additional cost per brace) c No Transfer Standard

c Pattern: _______________________________ c Provide Own Pattern