Upload
others
View
8
Download
0
Embed Size (px)
Citation preview
Thank you!© 2020 Cascade Dafo, Inc. All rights reserved. 38
Cascade Dafo, Inc.1360 Sunset Ave, Ferndale, WA 98248ph 800.848.7332 fax 855.543.0092
intl +1 360 543 9306 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
cVarus
cNeutral
cNeutral
cVarus
cValgus
c
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
c Rush order (adds $20)
Special Instructions
Order Turbo Softy Rev.11 (Apr 2020)
PF block, DF block, Softy liner
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 •
Liner: c Softy foam (white only) Standard c Polyethylene
c Add extra navicular padding (boney pronators only)
c Add plastizote to malleoli (recommended w. PE liner)
Straps: Standard(see drawing)
c Add D-ring/pad to ant. strap
c Add toe abduction strapStrapColor: c White
Standard c Other: Instep Strap Pattern: c
No pattern Standard c Other:
Turbo
Toe ShelfOuter Frame:
Inner Liner: Toe Shelf—Inner Liner
cFlexible — no containment Standard
c Medial
containment:
c Lateral
containment:
AND / OR
Non-StretchLayover Anterior Strap
with Felt Pad
Hei
ght
Length
MEDIAL (Left) LATERAL (Left)
InnerLiner
OuterFrame
Padding
Instep & Forefoot Straps
DA
FO®
cTrimmed just
proximal to met. heads under
plantar surface
cTrimmed distal
to met. heads under plantar
surface
TransferPattern: c No Transfer Standard
(Outer frame only; additional cost per brace)
c Pattern: _______________________________ c Provide OwnPattern
Toe Rise and Cuff Padding Color:
c White Standard c Other:
Non-StretchLayover Anterior Strap
with Felt Pad
Hei
ght
Length
MEDIAL (Left) LATERAL (Left)
InnerLiner
OuterFrame
Padding
Instep & Forefoot Straps
Non-StretchLayover Anterior Strap
with Felt PadH
eigh
t
Length
MEDIAL (Left) LATERAL (Left)
InnerLiner
OuterFrame
Padding
Instep & Forefoot Straps
cFull-length
under plantar surface
(for crouching)
Non-StretchLayover Anterior Strap
with Felt Pad
Hei
ght
Length
MEDIAL (Left) LATERAL (Left)
InnerLiner
OuterFrame
Padding
Instep & Forefoot Straps
(Full length toe shelf only)
NOTE: Neutral forefoot alignments will not see foam on toe shelf.