PF free, DF free
Transcript of PF free, DF free
Cascade Dafo, Inc.1360 Sunset Ave, Ferndale, WA 98248ph 800.848.7332 intl +1 360 543 9306fax 855.543.0092 www.cascadedafo.com
Construction | Features | Options
Thank you!© 2021 Cascade Dafo, Inc. All rights reserved. 7
Pat
ient
Last name:
First name:
Birth date: c Bilateral c Left c Right
Date cast:
Pra
ctit
ione
r Last Name:
First Name:
Title/Credentials:
Email: Phone:
Bill
ing
Customer/Business name:
Street address:
City: State: Zip:
PO# / UCAN#:
Shi
ppin
g
c Shipping info is the same as Billing info. –OR–
Shipping contact name:
Facility name:
Street address:
City: State: Zip:
Finished Brace Angles
ANKLE ALIGNMENT (Dorsiflexion-Plantarflexion)
c Correct to 3-4° DF c Correct to _______° c Do not correct
HINDFOOT ALIGNMENT
c 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 Varus Neutral Neutral Varus Valgus
c ______ c ______ c c c ______ c ______
c Do not correct - keep as cast. c Do not correct - keep as cast.
c DFc PF
(cast alignment OK)
Bottom Stabilization
c None– Standard
c Heel -OR- c Midfoot -OR- c Both -OR-
c Entire bottom stabilized with foam sole -OR-
c Entire bottom with non-skid cover only -OR-
c Entire bottom stabilized with both foam sole and non-skid cover
NOTE: Varus or valgus forefoot alignments will receive stabilization on bottom of brace to support posted (raised) region
NOTE: Neutral forefoot alignments will not see foam on toe shelf
Order 4 Rev.15 (May 2021)
PF free, DF free
DAFO® 4
Special Instructions
c Rush order (adds $20)
Toe Shelf
c Flexible — no containmentStandard
Medial containment
c Soft foam (flexible)
c Plastic
Lateral containment
c Soft foam (flexible)
c Plastic
AND / OR
TransferPattern: c No Transfer (Standard)
c Pattern: ____________________________
NOTE: Additional cost per brace.
Straps: Standard (see drawing) c Add toe abduction strap
Add Anterior Strap: c Non-stretch -OR- c Elastic NOTE: straps
will increase brace hieghtAdd Posterior
Strap: c Non-stretch -OR- c Elastic
StrapColor: c White (Standard) c Other: ______________
Instep StrapPattern: c No pattern (Standard) c Other: ______________
Padding: Shaded areas above are Standard
c Add extra navicular padding(boney pronators)
PaddingColor: c White (Standard) c Other: ______________
NOTE: If you don’t choose an option, you will receive the Standard.
Height: c Above malleoli(Standard) c Specify: _____________
NOTE: Cast height must be greater than brace height.
Instep & Forefoot Straps
MEDIAL (Left) LATERAL (Left)
Padding
Hei
ght
Length