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AFO Models Mile High Balance Brace Order Form

AFO Models Mile High Balance Brace Order Form
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AFO Models Mile High Balance Brace Order Form

Product catalog summary
Order Form Overview: This document is an order form for the Mile High Balance Brace, a type of Ankle-Foot Orthosis (AFO) provided by Mile High Orthotics Labs. It includes sections for billing and shipping information, patient details, and specific order customizations.
Billing and Shipping Information: The form requires the account name, address, city, state, zip code, phone, and fax numbers for both billing and shipping. There is an option to indicate if the shipping address is the same as the billing address.
Patient Information: The form collects the patient's name, gender, weight, age, and diagnosis. Diagnosis options include Posterior Tibial Tendon Dysfunction (PTTD), Degenerative Joint Disease, Severe Pronation, Trauma, or other specified conditions. It also specifies whether the brace is for the left, right, or both feet.
Customization Options: The form allows for customization of the brace color (black), closure type (all Velcro), and height (9 inches, as marked on cast, or other specified height). Cast modifications can be made at the lab's discretion, with options to correct the ankle to 90 degrees or leave as casted, and to correct the forefoot to neutral or leave as casted. All casts will be corrected to subtalar neutral unless specified otherwise.
Special Instructions: There is a section for any additional special instructions or requests for consultation.
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Catalog excerpts

AFO Models Mile High Balance Brace Order Form-1

Mile High Balance Brace Order Form 4970 MONACO ST. UNIT A COMMERCE CITY, CO 80022 OFFICE: 303.289.1534 TOLL FREE: 866.710.4880 FAX: 303.288.3687 www.mholabs.com Ship To Same as Bill Address: Account Name: 0□ Posterior Tibial Tendon Dysfunction (PTTD) □ Degenerative Joint Disease □ Severe Pronation □ Right □ Bilateral □ Black Closure Type: □ All Velcro® Height: (Measured from base Heel to top of collar) □ As Marked on Cast □ Other________ Cast Modifications: □ Correct to 90° □ Leave as Casted Forefoot: □ Correct to Neutral □ Leave as Casted Ankle: * All Cast Will Be Corrected To Subtalar Neutral Unless Specified Otherwise Please Call For Consult

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*Prices are pre-tax. They exclude delivery charges and customs duties and do not include additional charges for installation or activation options. Prices are indicative only and may vary by country, with changes to the cost of raw materials and exchange rates.