Thank you!© 2017 Cascade Dafo, Inc. All rights reserved. 16

Cascade Dafo, Inc.1360 Sunset Ave, Ferndale, WA 98248ph 800.848.7332 intl +00 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

cVarus

cNeutral

cNeutral

cVarus

cValgus

c

c Rush order (adds $25)

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

Special Instructions

Toe Shelf—Inner Liner

cFlexible — no containment Standard

 c Medial

containment:

 c Lateral

containment:

AND / OR

Order 2 Softy Rev.08 (Nov 2017)

DA

FO®

Hinged PF block, DF free, Softy liner

Non-StretchAnterior Strap

MEDIAL (Left) LATERAL (Left)

Instep & Forefoot Straps Hei

ght

Length

InnerLiner

OuterFrame

Padding

2

Special Instructions

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 •

InnerLiner:

c Softy foam (white only) Standard (outer frame extends to full-length)

c Polyethylene (outer frame trimmed at sulcus)

c Add extra navicular padding (boney pronators only)

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

StrapColor: c White

Standard c Other:

Instep Strap Pattern: c No pattern

Standard c Other:

TransferPattern: c No Transfer Standard

(Outer frame only; additional cost per brace)

c Pattern: _____________________________ cProvide Own Pattern

Toe Rise and Cuff Padding Color:

c White Standard c Other: