workorder #: ankle stabilizers - hanger fabricationheel cup 35 mm – standard 18 mm 14 mm other ___...
TRANSCRIPT
Bill To: Patient Name:
Address: Height: Left Male Weight: Right Female
Ship To: Age: Bilateral Address:
Practitioner:
Phone #:
OPS invoice / NG encounter:Date of Service:In-Office Request Date: am pm
Ankle stabilizer NL_2016_R1
Workorder #: (Lab Use Only)
Ankle Stabilizers
SURE-01 Standard
SURE-02 Pro Custom
SURE- 03 Dynamic Assist
SURE-08
Separate Uprights (Option)
Variable ROM
Custom lowerPre Fab upper
SURE-18 Lite
Please indicate any areas of concern.
Widest Calf
Mid Calf
Above Ankle
Ankle
Width at Met. Heads
Comments:
SURE-19 Stabilizer
From Heel to Finished Trim
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Separate uprights
Custom to castConnected Uprights
Separate Uprights (Option)
Custom to castConnected Uprights
Custom to castConnected Uprights
Separate Uprights (Option)
Custom to cast Custom to cast
Please ship cast and completed order form to: National Lab-Orlando 9561 Satellite Boulevard, Suite 350 Orlando, FL 32837 P (407) 852-6170 F (866) 855-1486 [email protected]
Plantarflexion
Hindfoot Subtalar Alignment
Neutral
Do Not Correct
Forefoot Alignment
Neutral
Do Not Correct
Other
Top Cover
Standard
Spenco Diabetic
Poron
Foot Plate Length
Standard (prox to met heads) Sulcus End of Toes
(weight bearing tracing required)
Heel cup
35 mm – Standard
18 mm
14 mm
Other ___
Joint Option
Full Flexion
Temporary Fixed
Permanent Fixed
90oDynamic Assist
Dorsi Assis Tamarackt
CAST ASSESSMENT AND MODIFICATIONS
Flexible
Addons
Heel Lift_________mm
Scaphoid (Medial) Sling
Cuboid (Lateral) Sling
Instep Strap
Foot Plate Accommodation
Navicular
Styloid
Medial Fascial Band
Other: _____________
Trimline
Forefoot Posting
Zero
Varus Degrees
Valgus Degrees
Arch Fill
Minimum – snug fit, no forgiveness
Standard – close conformity
Maximum – very forgiving
Top Cover Length
Metatarsals
Sulcus
Toes
Foot Orthosis width
Standard
Narrow
Low Profile Podiatric Trim
Medial Heel Skive 2º 4º 6º
Ankle Alignment
Neutral
Do Not Correct
Dorsiflexion ______o
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Additional charges may apply*
Other
ANKLE STABILIZER STANDARDS
SURE-01, 02, 03, 08 Foot plate cover: EVA Foot plate length: Proximal to met heads Heel cup: 35mm
SURE-18, 19 Padded soft covering Foot plate length: Proximal to met heads Heel cup: Custom to cast provided
Rigid/Fused
Comments:
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Foot/Ankle Condition
Hindfoot Posting
Degrees Zero
Varus
Valgus Degrees
Medial distal extension
Lateral distal extension (Use with abducted forefoot. Do not use with lateral ankle instability)