Ortho-AFO Brace Prescription Form
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65 PLAIN AVENUE
NEW ROCHELLE, NY 10801
914-235-9100 • FAX: 914-235-9697
800-473-6682
ortho-rite.com
FOR LAB USE ONLY
 
 
ACCOUNT# LOG #
 
SI   SO   INV.

The Ortho-AFO Brace

OFFICE NAME   DATE 
DOCTOR *   PHONE# * 
ADDRESS *   EMAIL * 
PATIENT NAME *   SEX      AGE  WEIGHT 
SHOE SIZE   TYPE WORN  OCCUPATION 
DIAGNOSIS AND
OBSERVATIONS
CAST TAKEN   NON WEIGHT BEARING  
SEMI WEIGHT BEARING   WEIGHT BEARING  

STYLES:
Leather Gauntlet AFO-Original 5"
Leather Gauntlet AFO-Original 9"
Leather Gauntlet AFO-Posterior Heel Window 5"
Leather Gauntlet AFO-Posterior Heel Window 9"
 
CLOSURE:
Lace (standard)
Velcro
Combination
Boot Hooks on Top Three Holes
 
COLOR:
Natural Russet Black
Brown Taupe
 
ADDITIONAL OPTIONS:
Line Inside Gauntlet with 1/8" Plastazote Foam  
Extended Foot Plate - FullFoot  
Partial Foot Toe Filler  
Extra Padding(Specifiy Area)
Other:
 
CAST PREPARATION INSTRUCTIONS:
Ankle: As Is Correct to 90o
Amount Dorsi Plantar
Hindfoot: As Is Correct to Neutral
Forefoot: As Is Correct to Neutral
 
ADDITIONAL INSTRUCTIONS :
 
 
1. Circumference at Metatarsal Heads
2. M-Lat Metatarsal Heads
3. Circumference at Ankle
4. M-Lat Ankle
5. Circumference at Mid Calf
6. M-L at Mid Calf
7. Height to Fibular Head
8. A.P Diameter heel to dorsum of foot
9. Circumference heel to dorsum of foot
 
Standard Leather Ankle Gauntlet AFO's Include:
 
  • Molded leather Cream Cow inside lining
  • Plastic reinforced ankle padded with 1/8* Aliplast
  • Natural Russet leather lacer
  • Lace Closure
  • Length of foot plate trimmed proximal to metatarsal heads
 
 
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© 2006 Ortho-Rite, Inc.
65 Plain Ave. • New Rochelle, NY 10801
(800) 473-6682 • (914) 235-9100 • Fax (914) 235-9697 • info@ortho-rite.com