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CLINIC PORTAL
Home
About
Services
Contact
CLINIC PORTAL
Thermoplastic AFO
ThermoPlastic AFO
Step
1
of
6
16%
Order Details
Clinician
*
Contact Phone
Contact Email
*
Due Date
Standard Turn Around
Rush Order (additional charges may apply)
Date Required
MM slash DD slash YYYY
We will do our best to meet your dealine!
Patient Details
Patient name/ID
*
Patient Weight (kg)
*
Patient Height (cm)
*
Activity Level
Non-Ambulatry
Medium
High
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
*
Solid AFO
Leaf Spring AFO
Elastic Jointed AFO
Articulated Bed-Resting AFO
Ground-Reactive AFO
Foot Style
*
Full Length
3/4 Length
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
Solid/Leaf Spring/ Ground Reactive AFO Manufacturing Details
Plastic Type
Polypropylene
CoPolymer
High Density Poly Ethylene
Plastic Thickness
2mm
3mm
4mm
5mm
6mm
Additional Details
Re-inforcement at Ankles
Encapsulate Dorsum of Foot
Stretch Plastic at Forefoot for Flexibility
Additional Bi-Valve Anterior Section
Optional Foam Lining
4.5mm Thermo-Foam (Ali-Plast)
6mm Thermo-Foam (Ali-Plast)
3mm EVA
Elastic Jointed AFO Manufacturing Details
Plastic Type
Polypropylene
CoPolymer
High Density Poly Ethylene
Plastic Thickness
3mm
4mm
5mm
6mm
Elastic Joint Size
Small
Medium
Large
Elastic Joint Style
Straight
Dorsi-Assist
Durometer
*
75
85
95
Plantar Flexion Stop
*
None
Adult Snap-Stop
Paediatric Snap-Stop
Re-enforced Plastic
Additional Details
Encapsulate Dorsum of Foot
Stretch Plastic at Forefoot for Flexibility
Bi-Valve Anterior Section
Ali-Plast/Thermo-Foam Lining
4.5mm Thermo-Foam (Ali-Plast)
6mm Thermo-Foam (Ali-Plast)
3mm EVA
Cosmetic Detail
Transfer Paper Colour
No Transfer
Ice Age
No Dogs
1 of 100 others...
Padding Colour
Black
White
Blue
Pink
Subject to availability
Strap Colour
*
White
Black
Yellow
Blue
Green
Red
Purple
Pink
Strapping
Shin/Calf Strap
*
One
None
Two
Ankle Strap
*
None
25mm Strap
Pronation Control Strap
Suppination Control Strap
Forefoot Strap
*
None
One
Additional Straps
Padding
Malleoli Padding
*
None
Medial
Lateral
Both
Plantar Padding
*
None
2mm EVA Foam
Calf Padding
*
No
Yes
3mm EVA Foam
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 Including Forefoot
Rocker Sole
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?
Left-Side Cast Corrections
Please carefully review your selection
Left Ankle Angle
*
Neutral/Plantigrade (SVA 5deg)
As Cast/Scanned
Dorsiflexion
Plantarflexion
Left Ankle Angle (degrees)
Left Calcaneal Angle
*
Neutral
As Cast/Scanned
Eversion
Inversion
Left Calcaneal Angle (degrees)
Left Toe Spring Angle
*
Standard
None
Other
Left Toe Spring Angle (degrees)
Left Shoe Pitch (mm)
Shoe pitch will be added last, additional to other angular corrections
Left-Side Forefoot Corrections
Left Forefoot Offset
*
Neutral
As Cast/Scanned
Abducted
Adducted
Left Forefoot Offset (degrees)
Left Rotation
*
Neutral
As Cast/Scanned
Inverted
Everted
Left Forefoot Rotation (degrees)
Left Trimline Circ. (mm)
Left Supra Malleolar M-L (mm)
Left Malleolar M-L (mm)
Left MetHead M-L (mm)
Left Trim Height (mm)
Left Trim Length (mm)
Right-Side Angular Cast Corrections
Right Ankle Angle
*
Neutral/Plantigrade (SVA 5deg)
As Cast/Scanned
Dorsiflexion
Plantarflexion
Right Ankle Angle (degrees)
Right Calcaneal Angle
*
Neutral
As Cast/Scanned
Eversion
Inversion
Right Calcaneal Angle (degrees)
Right Toe Spring Angle
*
Standard
None
Other
Right Toe Spring Angle (degrees)
Shoe Pitch (mm)
Shoe pitch will be added last, additional to other angular corrections
Right-Side Forefoot Corrections
Right Offset
*
Neutral
As Cast/Scanned
Abducted
Adducted
Right Forefoot Offset (degrees)
Right Forefoot Rotation
*
Neutral
As Cast/Scanned
Inverted
Everted
Right Forefoot Rotation (degrees)
Right Trimline Circ. (mm)
Right Supra Malleolar M-L (mm)
Right Malleolar M-L (mm)
Right MetHead M-L (mm)
Right Trim Height (mm)
Right Trim Length (mm)
Additional Information
