Facility: ___________________________ Street: ____________________________ City: ______________________________ State: ___________ Zip: ____________ Orthotist: __________________________ Phone No.: ___________________________________	Patient: ___________________________ Age: ____Sex: ____Ht: ____Wt:______ City: __________________ State: _____ Zip: ___________ Diagnosis: ___________________________ ____________________________________

OPTIONS D-5 GROWTH ADJ. LOOP D-6 GROWTH ADJ. LAP D-13 MOLDED CALF LACER *D-38 NON MOLDED CALF LACER D-16 UCB INSERT D-18 MOLDED BOOT D-19 STAINLESS STEEL FOOTPLATE D-20 ATTACH TO NON MOLDED SHOE D-20M ATTACH TO MOLDED SHOE D-21 T-STRAP D-22 GILLETTE JTS. D-22A TAMARACK JTS. D-22B TAMARACK JTS. DORSI ASSIST D-23 OKLAHOMA JTS. D-24 SCOTTY JTS. D-25 795 MOTION LIMITER D-26 COMPCORE REINFORCEMENT D-26A PLASTIC REINFORCEMENT

D-28 SOFT INTERFACE CALF D-29 SOFT INTERFACE FOOT D-32 ANTERIOR TIBIAL PANEL D-33 VENT HOLES D-34 FLARE D-35 CUT OUT D-37 TRAFO MODS. D-38 655 MOTION LIMITER D-39 755 MOTION LIMITER D-43 CAMBER AXIS JTS. D-51 PADS D-53 ST PADS D-54 POSTING D-69 TAMARACK VARIABLE ASSIST *D-80 1/16" P.E. TONGUED D-81 PELITE TONGUE D-81A REMOVABLE TONGUE D-82 ADDITIONAL VELCRO STRAP

Standard Choices: Ankle Joint _____________ Stirrup Model _______________ Leather/Velcro ____Black ____Brown ____Beige ____White (Check One) Upright Finish _____ Bead Blast _____ThermoClad (Black or White) ____High Buff Plastic ____ Thickness ____ Natural Only