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CLINIC PORTAL
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About
Services
Contact
CLINIC PORTAL
Fior and Gentz Carbon Fibre KAFO
Fior and Gentz Carbon Fibre KAFO
Step
1
of
5
20%
Order Details
Clinician
*
Contact Phone
Contact Email
*
Due Date
*
Standard Turn Around
Rush Order (25% rush fee applies)
Date Required (we will do our best to meet this timeline)
MM slash DD slash YYYY
Patient Details
Patient name/ID
*
Patient Weight (kg)
*
Patient Height (cm)
*
Activity Level
Non-Ambulatory
Low Activity (equivalent K1-2)
Med Activity (equivalent K3)
High Activity (equivalent K4 and above)
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
Do you require a plastic check-fit Orthosis to test fit?
*
Yes
No
Check-Fit Details
Solid Check-Fit (without joints)
Knee Joint and Fixed Ankle
Knee Joint and Free-Motion Ankle joint
Have you completed the Fior & Gentz Online Configurator?
*
Yes
No
Configurator File
Accepted file types: stl, cvx, o01, obj, ply, vsrf, Max. file size: 2 MB.
Please supply the pdf printout from the configurator
Will you be posting/supplying components
No
Yes
What Components will you send?
Manufacturing Details
Thigh Shell Design
*
Posterior Only
Anterior Only
Posterior with removable anterior section
Calf Shell Design
*
Posterior Only
Anterior Only
Posterior with removable Anterior
Additional Components Required?
Cosmetic Detail
Carbon Finish
*
Carbon-Fibre (Standard)
Patterned Fabric Finish
Custom Paint (please contact us for options)
Fabric Pattern
First Choice
Second Choice
Third Choice
Strap Colour
*
Black
White
Yellow
Blue
Green
Red
Purple
Pink
Strapping
Thigh Straps
*
None
2 Straps
3 Straps
Shin/Calf Strap
*
One
None
Ankle Strap
*
None
25mm Strap
Pronation Control Strap
Suppination Control Strap
Lining and Padding
Lining
*
3mm EVA
Comfortex
Additional Mal Padding
None
Medial Only
Lateral Only
Both
Additional Spot Padding
No
Yes
3mm EVA Foam
Spot Pad
Soling Details
Heel Raise
None
Heel Stabiliser Only
Heel Raise to MH
Full Length Raise
Raise Height Under Heel (cm)
*
Raise Height Under MH (cm)
*
Post Heel?
None
Post Medially
Post Laterally
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 Angular Cast Corrections
Please carefully review your selection
Corrected Side
Left
Right
Knee Angle
*
Neutral
As Cast/Scanned
Flexion
Knee Flexion Angle (degrees)
Ankle Angle
*
Neutral/Plantigrade (SVA 5deg)
As Cast/Scanned
Dorsiflexion
Plantarflexion
Calcaneal Angle
*
Neutral
As Cast/Scanned
Eversion
Inversion
Calcaneal Angle (degrees)
Toe-Out Angle
*
Neutral
As Cast/Scanned
Toe-Out
Toe-In
Toe Angle (degrees)
Toe Spring Angle
*
Standard
None
Other
Toe Spring Angle (degrees)
Shoe Pitch (mm)
Additional to other angular corrections
Encapsulate Met Heads
*
None
First MH Only
Fifth MH only
Both First and Fifth MH
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)
Trimline Circ. (mm)
SupraPatellar Circ. (mm)
SupraPatellar M-L (mm)
Knee M-L (mm)
Supra Malleolar M-L (mm)
Malleolar M-L (mm)
MetHead M-L (mm)
Prox. Lat. Trim Height (mm)
Med. Lat. Trim Height (mm)
SupraPatellar Height (mm)
KJC Height (mm)
Calf Trim Height (mm)
SupraMal Height (mm)
SupraMal Height (mm)
MH Length(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
Encapsulate Met Heads
*
None
First MH Only
Fifth MH only
Both First and Fifth MH
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)
Trimline Circ. (mm)
Trimline Circ. (mm)
SupraPatellar Circ. (mm)
SupraPatellar M-L (mm)
Knee M-L (mm)
Supra Malleolar M-L (mm)
Malleolar M-L (mm)
MetHead M-L (mm)
Prox. Lat. Trim Height (mm)
Med. Lat. Trim Height (mm)
SupraPatellar Height (mm)
KJC Height (mm)
Calf Trim Height (mm)
SupraMal Height (mm)
SupraMal Height (mm)
MH Length(mm)
Trim Length (mm)
2nd Specific Offloading and Additional Information
Any Additional Information
