Elbow/Wrist Orthosis

20%

Order Details
Clinician*
Contact Phone
Contact Email*
Due Date*
- Standard Turn Around
- Rush Order (25% rush fee applies)
Date Required
MM slash DD slash YYYY
Patient Details
Patient name/ID*
Patient Weight (kg)*
Patient Height (cm)*
Activity Level
Model Details
Side*
- Left
- Right
- Bilateral
Model Details*
- I am providing a MODIFIED scan
- I am providing an UNMODIFIED scan
- I am posting a negative cast
- I am posting a modified plaster model
Scan File
Accepted file types: stl, cvx, o01, obj, ply, vsrf, Max. file size: 2 MB.
We will accept scans in the following formats: .stl .cvx .o01 .obj .vsrf .ply
I will be posting/supplying components
- No
- Yes

Orthosis Style
Orthosis Type*
Foot Style*
Encapsulate Met Heads*
- None
- First MH Only
- Fifth MH only
- Both First and Fifth MH
Foot Length (cm)*

measured from back of heel
Proximal Trim Height (cm)*

measured from base of heel

Cosmetic Detail
Transfer Paper Colour
Padding Colour
Subject to availability
Strap Colour*
Strapping
trim1
Shin/Calf Strap*
- One
- None
Ankle Strap*
- None
- 25mm Strap
- Pronation Control Strap
- Suppination Control Strap
Forefoot Strap*
- None
- One
Padding
Malleoli Padding*
- None
- Medial
- Lateral
- Both
Plantar Padding*
- None
- Foam
- Leather
Calf Padding*
- No
- Yes
3mm EVA Foam
Additional Spot Padding
- No
- Yes
3mm EVA Foam
Spot Pad
Soling Details
Heel Raise
Raise Height Under Heel (cm)*
Raise Height Under MH (cm)*

Cast Corrections
Corrections Are:
- Identical Left and Right
- Different Left and Right
Are the cast corrections the same on each side?
Anglular Cast Corrections
Please carefully review your selection
Left Side Anglular Cast Corrections
Please carefully review your selection
Corrected Side
- Left
- Right
Ankle Angle*
- Neutral/Plantigrade (SVA 5deg)
- As Cast/Scanned
- Dorsiflexion
- Plantarflexion
Ankle Angle (degrees)
Calcaneal Angle*
- Neutral
- As Cast/Scanned
- Eversion
- Inversion
Calcaneal Angle (degrees)
Toe Spring Angle*
- Standard
- None
- Other
Toe Spring Angle (degrees)
Shoe Pitch (mm)

Additional to other angular corrections
Forefoot Corrections
Left Side Forefoot Corrections
Offset*
- Neutral
- As Cast/Scanned
- Abducted
- Adducted
Forefoot Offset (degrees)
Rotation*
- Neutral
- As Cast/Scanned
- Inverted
- Everted
Forefoot Rotation (degrees)
Trimline Circ. (mm)
Supra Malleolar M-L (mm)
Malleolar M-L (mm)
MetHead M-L (mm)
Trim Height (mm)
Trim Length (mm)
Specific Offloading and Additional Information

Right Side Angular Cast Corrections
The Other Side
2nd Corrected Side
- Left
- Right
2nd Ankle Angle*
- Neutral/Plantigrade (SVA 5deg)
- As Cast/Scanned
- Dorsiflexion
- Plantarflexion
2nd Ankle Angle (degrees)
2nd Calcaneal Angle*
- Neutral
- As Cast/Scanned
- Eversion
- Inversion
2nd Calcaneal Angle (degrees)
2nd Toe Spring Angle*
- Standard
- None
- Other
2nd Toe Spring Angle (degrees)
Shoe Pitch (mm)

Additional to other angular corrections
Right Side Forefoot Corrections
2nd Offset*
- Neutral
- As Cast/Scanned
- Abducted
- Adducted
2nd Forefoot Offset (degrees)
2nd Rotation*
- Neutral
- As Cast/Scanned
- Inverted
- Everted
2nd Forefoot Rotation (degrees)
2nd Specific Offloading and Additional Information
Trimline Circ. (mm)
Supra Malleolar M-L (mm)
Malleolar M-L (mm)
MetHead M-L (mm)
Trim Height (mm)
Trim Length (mm)

Australia’s first Orthotic & Prosthetic manufacturing facility offering central fabrication and carving using industry-leading CAD/CAM technologies.

Order Details