Author: Tandyman

Patient Information Name:
___________________________ Left Weight:_________ Right Activity Level: ____ Bilateral

Prep

Fill/Modify are typically 1 unit for pediatric, 2 for adult, and 3 for large AKs/hips/chest

FF Fill FM Modify Adjust Cast

525 N. Steelhead Boise, ID 83704 208-429-0026

Laminated AFO Workorder Rev. 03252026

PO#: ______________ Date Needed: ____________

Received: ______________By: _____ Rush Charge Lab use only

Practitioner: _________________________________ Company: __________________________________ Address:____________________________________ City, State, Zip:______________________________ Email:______________________________________ Phone:_____________________________________

Ship to (if different): _________________ _________________________________ _________________________________ Shipping Method:___________________ UPS/Fedex #:______________________

AFO Type

Lamination

Finish

Pigment

Modifications

Standard modifications are no reductions on AFOs with 1/8” ankle buildup

FAST Solid Ankle FAAL Art. Ankle FABV Boise Bi FPFA Partial Foot

Inner Boot

Light Standard FHDL Heavy Duty

Plastic

Braid Solid Fabric

Black Beige White
Other
__________

Thickness

Fib Head Height ______

Brace Height ______

FAIB Yes No

Boot Trimline

3/4 Total Contact FATHD* ProComp

Joints

Lateral

PolyPro CoPoly MPE

Medial

3/32” 5/32” FATHD* ProComp

1/8” 3/16”

Lateral Buildup ______

Medial Buildup ______

ZTJ Tamarack Dorsi _____ Free Motion ZBD Double Action Spring _____ Pin _____

ZTJ Tamarack Dorsi _____ Free Motion ZBD Double Action Spring _____ Pin _____

90° Stop

Heel Wedge

Insole / Support

Yes No

FAHB Yes No

Lateral Medial

ZPIS Petite Insole ____ PerLayer Neutral to Bench
Distance from Neutral ______

Straps

Ankle

Center

Calf

Color

ZS1 Velcro 1”- 1.5” ZSHD1 Dacron 1”- 1.5” ZSV1 Velstretch 1”- 2”

Black White

Attach Straps

Ant. Shell

Yes No

FASS Simple Shell FAAS Molded Shell

Box/Cap Toe

Full

Sulcus

Prox Met

Mod Notes

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Add. Padding

Thickness

Pad Type

Hourly Labor

FHL ___ ___________________________________

ZAA Yes No

(Black) (Black) (Skin) (White)

Ankle Plantar Calf Other: _________

Quality Assurance

Smooth edges Symmetrical trim Pads glued/Incl. Straps On/Incl. Strap placement

Puff Plast P.Cell Aliplast Puff Plast P.Cell Aliplast Puff Plast P.Cell Aliplast Puff Plast P.Cell Aliplast Puff Plast P.Cell Aliplast

Joint Alignment Comp. Loctited All parts Incl. Proj. tote cleared Engraved P.O.

Mods Pull Finish QA ________ Finish Date

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Send cast/parts to: Coyote, 525 N. Steelhead Boise, ID 83704

Additional Notes

Plastic

PolyPro CoPoly FATHD* - Heavy Duty FTPC ProComp 1/4”

Thickness

3/32” 5/32” 1/4”* ProComp

1/8” 3/16”

Transfer Paper

ZTP

FAHB

Yes ZAA No