Foot Ox /UCB 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: Practitioner: P.O. #:

Patient Name: Bill To: Ship To:

Affected Side: ■ Left ■ Right ■ Bilateral

Device: ■ Partial Foot ■ FO ■ F O w/UCB
Cast Ready to be Poured? ■ Yes ■ No ■ Ground ■ 2 Day ■ Next Day

FOOT O X / U C B o r d e r d e s c r i p t i o n

1 Modification: 3 Foot Ox: ■ N/A

■ Minimal ■ Standard Customized: Thickness & Material: Length:

■ Toe Reducing ■ Other 1st Layer (against foot) ■ Full ■ Sulcus ■ Met
2nd Layer ■ Full ■ Sulcus ■ Met
2 Footplate: 3rd Layer ■ Full ■ Sulcus ■ Met
Other ■ Full ■ Sulcus ■ Met
■ Full Length ■ Sulcus Length
Standard Foot Orthoses:
■ Metatarsal Length
■ Leather / 1/8" ppt / Cork ■ 1/8" plastazote / 1/8" ppt / Blue Puff ■ Carbon
■ Other
Met Bar:
ADDITIONA L INSTR U C TIONS : ■ Yes ■ No ■ Small ■ Medium ■ Large
Met Pads:
■ Yes ■ No ■ Small ■ Medium ■ Large
Morton’s Extension: Toe Filler:
■ Yes ■ No ■ Yes ■ No ■ Part of Device (No Seams)
■ Separate Piece (Attach at Fitting)
Circle Toes Missing: Left: 1 2 3 4 5 Right: 1 2 3 4 5

4 UCB: ■ N/A
Material:
■ Polypro ■ Copoly ■ Other
Thickness:
■ 3/32" ■ 1/8" ■ 5/32" ■ 3/16" ■ 1/4"
Dorsal Flaps: Color:
■ Yes ■ No ■ Natural (White) ■ Other
Forefoot Trim:
■ Extend Laterally ■ Extend Medially ■ Extend Both ■ Full Forefoot Wrap

5 Posting: ■ N/A
Fore Foot:
■ Intrinsic ■ Post to these Values:
■ Extrinsic to: ■ Meta ■ Sulcus Left: Varus/Valgus
Right: Varus/Valgus

Rear Foot:
■ Intrinsic ■ Extrinsic ■ Post to these Values:
Left: Varus/Valgus
Right: Varus/Valgus

2014.11_1.1