Leather Gauntlet/Crow Order Form

8647 W. 95th Street • Hickory Hills, IL 60457 • ( T ) 866.914.AOPS • ( T ) 708.237.4099 • ( F) 708.598.2857

(2677)

Pa t i e n t I n f o r m a t i o n

Today’s Date: Due Date: Account #: P.O. #:

Patient Name: Facility: Practitioner:

Patient ID #: Bill To: Ship To:

Sex: ■ M ■ F Affected Side: ■ Left ■ Right ■ Bilateral

Age: Height: Weight: ■ Ground ■ 2 Day ■ Next Day

L EAT H ER AN K L E G A U NT L ET o r d e r DE S C RI P TION

1 Device: ■ N/A 3 Patient Modifications: ■ N/A

Style: Range of Motion:
■ Leave Cast As Is ■ Correct to Neutral
■ Alpha ■ Beta ■ Gamma ■ Delta ■ Other:
Wrap Around Posterior Support Leather with Articulated
with Cut Outs Malleolli Poly Pro Plastic Extension Forefoot:
Copoly 3/32" 5/32" Poly Pro 3/16" ■ Leave as in Cast ■ Correct to Neutral
Foot Plate:
2 Materials: ■ N/A ■ Full Foot Plate ■ Sulcus Foot Plate
Closure: ■ Velcro ■ Laces ■ Speed Lace Proximal Knee:
■ Combination (lace distal/velcro proximal) ■ Knee affects leg angle
■ Genu Varum:
Plastic: ■ Seaflex 200 ■ Seaflex 300 ■ Copoly ■ Poly Pro ■ Genu Valgum:
Footboard:
Color: ■ 1. Sand ■ 3. Dr. Taupe ■ 5. Chestnut Brown ■ 7. Black
■ Mold was taken using a footboard
■ 2. Lt. Taupe ■ 4. Discontinued ■ 6. Russet Brown
Height of board:

ence
C RO W o r d e r DE S C RI P TION
Impression
1 Device: ■ N/A 2 Design: ■ N/A
Measurements L eng t h s
Cast Ready to Be Poured: Design Details: ■ Inches
■ Yes ■ No Modification: ■ Centimeters

Ankle Set In: Ox Height

Charcot Restraint Orthotic Walker:

Foot Length:
• Copoly construction w/reinforced ankles
Standard modification is to add 1'' to above
• Fully lined with aliplast, 1/8'' PPT
trapped under sole
Color:
• Additional aliplast pad over instep
before aliplast anterior shell is formed Extra Insole: ■ Yes ■ No
Metatarsal ML: Lift:
• Removable 1/4 molded plastazole insole
• Four dacron reinforced straps: top calf, Fracture Socks: ■ Yes ■ No ANKLE
distal calf, 45° at ankle, over forefoot Quantity: ■ Varus ■ Valgus
• Firm crepe sole with rocker bottom Size: ■ Fexible ■ Rigid
Degrees:

a d d i t i o n a l i n s t r uc t i o n s ■ Toe Out ■ Toe In

■ Return casts Degrees:

Heel Height:

Foot Length:

Device Toe Plate Length:

2014 .11_1.1