574 Robbins Dr. Troy, MI 48083 Phone: 800-521-2192 Patient: Sex: BeckerOrthopedic.com ORDER INFORMATION PATIENT INFORMATION Age: Fax: 248-588-4555 PO#: Height: Warranty Information Weight: Diagnostic Check Orthosis (DCO) Diagnosis: PR ACTIONER SHIPPING INFORMATION Yes I understand the AFO will not be covered by the fit warranty if a DCO is not ordered. No If no, please sign Facility: Clinician: Signature Date TRIMLINE SELECTION Address: Footplate Length City: Zip: Full Foot Length* Sulcus Length Phone (Cell): Footplate Control State/Province/Region: Country: Phone (Office): Fax: Email: Full Control* Long Medial ( Supination Control) DE VICE SELECTION Single Upright Single Upright Flat Footplate** Total Contact Left Double Upright Total Contact Left Right Left Right Right Long Lateral (Pronation Control) Ankle Control None* Medial Supramalleolar Flare Lateral Supramalleolar Flare Liners / Padding / Inserts ME ASUREMENTS None* + Extra Navicular Padding Plantar Footplate Finished Height Calf Section Anatomical Ankle M/L FOREFOOT ALIGNMENT Ankle Joint Alignment Mechanical* Anatomical Neutral* Varus Valgus Coronal Hindfoot Alignment Do not correct Correct to vertical* Do not correct Correct to 4° DF* Correct to ° Correct to DF PF Heel Lift Height _______ SMO None* Polyethylene EVA Bilateral AFOs Size CAST CORRECTION Ankle Alignment (dorsiflexion/plantarflexion) Heel Forefoot Triple Action Lateral / Triple Action Medial Triple Action Lateral / Camber Axis ATA Medial Camber Axis ATA Lateral / Triple Action Medial Other: Sagittal Ankle Correction None* Triple Action Lateral / No companion joint Triple Action Medial / No companion joint Left Neutral* Footplate Stabilization Unilateral AFOs Right Varus + JOINT SELECTION (VARUS/VALGUS) Select Finished Alignment: Valgus Please check the appropriate box to select finish trimlines Varum ° Valgum Note: If you don’t choose an option, the * (default) option will be selected for you. AFO From Scan Orthometry Form required when providing scanned model. **Only available with single upright B size Triple Action. Product Information (Scan QR code for sizing) A size B size Booster Options No Booster DF Resist Booster PF Resist Booster *Refer to Triple Action Product Manual to select number of components and booster springs. SPECIAL INSTRUCTIONS