Author: Tandyman

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

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

Plastic AFO Workorder Rev. 03252026

Received: ______________By: _____ Rush Charge Lab use only

PO#: ______________ Date Needed: ____________

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

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

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

AFO Type

Plastic

Thickness

Modifications

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

FAST Solid Ankle FALS Leaf Spring FAAT Art. Ankle FABVP Boise Bi

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

3/32” 5/32” 1/4”* ProComp

1/8” 3/16”

Fib Head Height ______

Brace Height ______

Transfer Paper

ZTP

Inner Boot

Plastic

Yes FAIB No

PolyPro CoPoly MPE

Boot Trimline

Thickness

3/4 Total Contact FATHD* ProComp

3/32” 5/32” FATHD* ProComp

1/8” 3/16”

Joints

Medial

Lateral Buildup ______

Medial Buildup ______

Lateral

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

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

Box/Cap Toe

Prox Met

90° Stop

Heel Buttress

FAHB

Sulcus

Yes No

Lateral Medial

Full

Insole Support / External sting

ZPIS Pelite Insole (per layer) Neutral to Bench Distance from Neutral ____

____

Mod Notes

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Straps

Ankle

Center

Calf

Color

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

Black White FATHD* ProComp

Attach Straps

Yes No

Add. Padding

Thickness

Pad Type

Yes ZAA No

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

Ankle Plantar Calf Other: _________

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

Hourly Labor

FHL ___ ___________________________________

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

Additional Notes

Quality Assurance

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

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

___ Mods ___ Pull ___ Finish ___ QA ________ Finish Date