cascade dafo, inc. o f a softback 1360 sunset ave ... · 1360 sunset ave, ferndale, wa 98248 ph...
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Thank you!© 2019 Cascade Dafo, Inc. All rights reserved. 60
Cascade Dafo, Inc.1360 Sunset Ave, Ferndale, WA 98248ph 800.848.7332 intl +00 1 360 543 9306fax 855.543.0092 www.cascadedafo.com
Pat
ient
Last name:
First: c Male c Female
Date cast: / / c N c W
Birth date: / / c Bilateral c Left only c Right only
Pra
ctit
ione
r
Name: Title:
Facility:
Street address:
City: State: Zip: Email: Phone:
Bill
ing
c Cascade P&O is billing the patient’s insurance. –OR–
—UCAN No :
c Billing info is the same as practitioner facility. –OR–
c Billing facility:
Street address:
City: State: Zip:
P.O. No :
Shi
ppin
g
c Shipping info is the same as practitioner facility. –OR–
Shipping contact name:
Street address:
City: State: Zip:
Finished Brace AnglesANKLE ALIGNMENT (Dorsiflexion–Plantarflexion)
c Correct to 3–4° DF c Correct to ° c Do not correct
HINDFOOT ALIGNMENTc Correct to vertical (if misaligned) c Do not correct
FOREFOOT ALIGNMENT NOTE: Drawings show finished orthosis.
Choose forefoot alignment. Write posting height if needed—in. or mm.
RIG
HT
RIG
HT
RIG
HT
LEFT
LEFT
LEFT
Valgus
c
Varus
c
Neutral
cNeutral
cVarus
c
Valgus
c
c Rush order (adds $25)
Construction • Features • Options
(Cast alignment OK)
Bottom Stabilization
c None—Standard NOTE: Varus or valgus forefoot alignments will receive stabiliza-tion on bottom of brace to support posted (raised) region.c Heel -OR- c Midfoot -OR- c Both
c Entire bottom stabilized with foam sole
c Entire bottom stabilized with foam sole and non-skid cover
c DFc PF
Special Instructions
Toe Shelf—Inner Liner
cFlexible — no containment Standard
c Medial
containment:
c Lateral
containment:
AND / OR
PF resist, DF free, Softy liner
Order DAFO Softback Softy Rev.3 (April 2019)
NOTE: If you don’t choose an option, you will receive the Standard.
Liner: Softy foam (white only) Standard
c Add extra navicular padding (boney pronators only)
Instep & Forefoot Straps:
Standard (see drawing)
c Add toe abduction strap
StrapColor: c White
Standard c Other:
Instep Strap Pattern: c
No pattern Standard c Other:
MEDIAL (Left) LATERAL (Left)
Instep & Forefoot Straps
Proximal StrapLiner
TransferPattern:
(Additional cost per brace) c No Transfer Standard
c Pattern: _______________________________ c Provide Own Pattern
Softback™
DA
FO®
Special Instructions
Toe Shelf—Inner Liner
cFlexible — no containment Standard
c Medial
containment:
c Lateral
containment:
AND / OR
c Rush order (adds $25)