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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. 9

Pat

ient

Last name:

First name:

Birth date: Bilateral Left 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

Shipping info is the same as Billing info. –OR–

Shipping contact name:

Facility name:

Street address:

City: State: Zip:

Finished Brace Angles

HINDFOOT ALIGNMENT

Correct to vertical (if misaligned) Do not correct

FOREFOOT ALIGNMENT NOTE: Drawings show fi nished 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

______ ______ ______ ______

Do not correct - keep as cast. Do not correct - keep as cast.

Bottom Stabilization

Midfoot & Medial Heel– Standard

Heel -OR- Midfoot -OR- Both -OR-

Entire bottom stabilized with foam sole -OR-

Entire bottom with non-skid cover only -OR-

Entire bottom stabilized with both foam sole and non-skid cover

None

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 5 Rev.16 (May 2021)

Maximum control foot orthosis

DAFO® 5

Special Instructions

Rush order (adds $20)

Toe Shelf

Very Flexible (Standard) Full length plastic

FOAMPLASTIC TRIMMED PROXIMAL TO 1ST MET. HEAD, DISTAL TO 5TH

PLASTIC TRIMMED DISTAL TO TOES

TransferPattern: No Transfer (Standard)

Pattern: ____________________________

NOTE: Additional cost per brace.

NOTE: If you don’t choose an option, you will receive the Standard.

Padding: Shaded areas above are Standard

Add extra navicular padding(boney pronators)

PaddingColor: White (Standard) Other: _____________

MEDIAL (Left) LATERAL (Left)

Padding

FOAMPLASTIC TRIMMED PROXIMAL TO 1ST MET. HEAD, DISTAL TO 5TH

PLASTIC TRIMMED DISTAL TO TOES

Length

Plastic trimmed proximal to 1st met. head, distal to 5th

Foam extension attached

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