AFO Braces Form

    6324 Bass Lake Road, Suite D

    Crystal, MN 55428

    Tel:612-730-1222                  Fax: 763-951-3637

    Email: Thomas@topfinc.com
                www.topfinc.com

    CUSTOMER INFORMATION

    ORDER DATE

    DATE NEEDED

    FACILIT

    PO

    PRACTITIONER

    ADDRESS

    CITY/STATE

    PHONE

    FAX

    EMAIL

    SHIPPING INFORMATION

    NEXT DAY AIR

    2ND DAY AIR

    3RD DAY AIR

    GROUND

    PATIENT INFORMATION

    NAME

    MALE

    FEMALE

    AGE

    HT

    WT

    DX

    LEVEL OF INVOLVEMENT

    L

    R

    B

    FABRICATION INSTRUCTIONS

    All measurements must be provided and wounds should be marked on the above illustration.

    TYPE OF AFO

    CAST CORRECTIONS


    SOLE STYLE

    INNER MOLDED BOOT (1/2 firm puff standard thickness)

    MATERIALS

    Carbon fiber**(specify choice)
    Black Beige Light Brown Laminate

    Additions**