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

OPTIONS D-1 HKAFO UNI D-2 HKAFO BI D-3 ISCHIAL RING D-4 ISCHIAL SEAT D-5 GROWTH ADJ. LOOP D-6 GROWTH ADJ. LAP D-7 BALL CATCH D-8C SPRING PULL INSTALLED D-9 5 BUCKLE KNEE PAD D-10 4 BUCKLE D-11 3 BUCKLE D-12 MOLDED LEATHER THIGH LACER D-13 MOLDED LEATHER CALF LACER *D-36 NON MOLDED THIGH LACER *D38 NON MOLDED CALF LACER D-14 ROUND CONDYLE D-15 PEAR CONDYLE D-16 UCB INSERT D-18 MOLDED LEATHER 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 REINFORCEMENTS D-26A PLASTIC REINFORCEMENTS D-27 SOFT INTERFACE THIGH D-28 SOFT INTERFACE CALF D-29 SOFT INTERFACE FOOT D-30 QUAD BRIM D-31 ANTERIOR FEMORAL PANEL D-32 ANTERIOR TIBIAL PANEL D-33 VENT HOLES D-34 FLARE D-35 CUT OUTS D-37 TRAFO MODS D-38 655 MOTION LIMITER D-39 755 MOTION LIMITER D-43 CAMBER AXIS JTS. D-51 PADS D-52 CABLE RELEASE SYSTEM INSTALLED D-53 ST PAD D-54 POSTING D-69 TAMARACK VARIABLE ASSIST *D-80 1/16" P.E. TONGUE D-81 PELITE TONGUE D-81A REMOVABLE TONGUE D-82 ADDITIONAL VELCRO STRAP
Standard Choices:
Knee Joint Model #_______________ Contoured Knee Joints _______ Medial _______Lateral (Check One) Upright Size _______- Aluminum _______- Stainless Steel Ankle Joint Model #______________ Stirrup Model # __________________	Leather/Velcro ____Black ____Brown (Check one) ____Beige ____White Upright Finish _____ Bead Blast _____ThermoClad (Black or White) ____High Buff Plastic ____ Thickness ____