AFO - International Orthotic...
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Sure Step Standard and Pro-Custom Order Series Form A3415 The SURE-01 is our Standard custom articulated functional AFO with standard independent semi-rigid uprights, custom balanced footplate with low profile footplate trimlines, standard EVA topcover, 35mm heel cup, ankle axis articulation placement, compression molded removable interface pads and velcro closures. Ankle high cast mold is neccesary for SURE-01 ................................................ ................................................................................ Sure Step Standard Custom (SURE-01) The SURE-02, SURE-03, SURE-06, and SURE-08 are our Premier custom AFO’s with custom upright supports molded to the individual’s lower leg for an intimate fit. The added structural integrity of the posterior bar offers the practitioner an array of ankle joint options that enhances R.O.M. without compromising the bracing function. These braces include custom balanced footplates with traditional lower medial and lateral flange, 35mm heel cup, custom ankle axis alignment, and compression molded removable foam interface pads. Mid-leg cast mold is neccesary for SURE-02, SURE-03, SURE-06, SURE-08 Sure Step Pro Custom Series (SURE-02, SURE-03, SURE-06, SURE-08) Bill To 1 Company Account Number Contact Person Address City/State/Province, Zip Postal Country Phone Purchase Order Number Fax Ship to (if different than bill to information) Name Address City/State/Province, Zip Postal Country Phone Fax Next Day 2nd Day* Ground Ship Method 2 ................................................................................ FREE for your next order! 3 With each shipment, Trulife provides a mid-calf casting sock FREE of charge. Please specify the desired size. If size is not specified, size medium will be sent. Medium Large X-Large None at this time Important: Please carefully complete all fields. Incomplete information may result in delayed processing of your order. *Standard Shipping is 2nd Day at Ground Rate
Transcript of AFO - International Orthotic...
Sure Step Standard and Pro-Custom Order Series Form A3415
The SURE-01 is our Standard custom articulated functional AFO with standard independent semi-rigid uprights, custom balanced footplate with lowprofile footplate trimlines, standard EVA topcover, 35mm heel cup, ankle axisarticulation placement, compression molded removable interface pads and velcro closures.
Ankle high cast mold is neccesary for SURE-01
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Sure Step Standard Custom (SURE-01)The SURE-02, SURE-03, SURE-06, and SURE-08 are our Premier custom AFO’s with custom upright supports molded to the individual’s lower leg for an intimate fit. The added structural integrity of the posterior bar offers the practitioner an array ofankle joint options that enhances R.O.M. without compromising the bracing function.These braces include custom balanced footplates with traditional lower medial and lateral flange, 35mm heel cup, custom ankle axis alignment, and compression moldedremovable foam interface pads.
Mid-leg cast mold is neccesary for SURE-02, SURE-03, SURE-06, SURE-08
Sure Step Pro Custom Series (SURE-02, SURE-03, SURE-06, SURE-08)
Bill To
1
Company
Account Number
Contact Person
Address
City/State/Province, Zip Postal Country
Phone
Purchase Order Number
Fax
Ship to (if different than bill to information)
Name
Address
City/State/Province, Zip Postal Country
Phone Fax
Next Day 2nd Day* GroundShip Method
2
................................................................................
FREE for your next order!
3
With each shipment, Trulife provides a mid-calf casting sock FREE of charge. Please specify the desired size. If size is not specified, size medium will be sent.
Medium Large X-Large None at this time
Important: Please carefully complete all fields. Incomplete information may result in delayed processing of your order.
*Standard Shipping is 2nd Day at Ground Rate
AFO.qxd 5/2/07 1:45 PM Page 19
Sure Step Standard and Pro-Custom Functional AFO
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Patient Information (Confidentially and securely maintained)
Name
Date
Occupation
Age
Left
Diagnosis
Activities
Sex Height Weight
Brace Side:
Right
Bilateral
Full FlexionAnkle Pivot Options:
Temporary Fixed
Permanent Fixed (SURE-06)
Dynamic Dorsi-Assist (SURE-03)Pre-flexed Assist
R.O.M (SURE-08)
Standard (E.V.A.)Top Cover:
Implus*
Spenco*
Add Poron Cushion To Extension*
Diabetic* (Plastazote / poron)
To MetsTop Cover Length:
To Sulcus (Standard)
To Toes
To Mets (Standard)Length Of Plastic Distally:
To Sulcus
To Toes
StandardFoot Orthosis:
Narrow
35mm (Standard)Heel Cup:
18mm
14mm (Sport shoes)
10mm (Sport shoes)
StandardHeel Stabilizer:
Wide
Varus_____DegreesForefoot Posting:
Valgus_____Degrees
Zero
Standard LengthLength Of Forefoot Post:
Extend To Sulcus
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Heel lift*:_______________mmAdditions / Accommodations:
Add high flange to 1st ray
Add lateral flange to 5th ray (Use with abductionforefoot, do not use with lateral ankle instability)Orthotic plate accommodation* (Mark location on cast)
Navicular* Medial fascial band*
Styloid 5th met* Other:_________________
Forefoot extension accommodation location*(Please mark on cast and on diagrams special instructions)
Minimum (Snug fit, no forgiveness)Arch Fill (Determines fit of orthotic of foot):
Standard (Close conformity, some forgiveness)
Maximum (Very forgiving)
According to cast (Standard)Cast Correction Intrinsic Posting*:
None (Leave positive ‘as is’)
According to measurement belowLeft: _____ Varus:_____ Valgus:_____ Right:_____ Varus:_____ Valgus:_____
2 DegreesMedial Heel Skive:
4 Degrees
6 Degrees
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Special Instructions:
*Additional charges may apply. See price sheet.
Send cast and order form to:Trulife Custom Sure Step Lab 26296 Twelve Trees Lane NW Poulsbo, WA 98370
Diameters Lengths Circumferences
90°
Ankle MLForefoot
ML
SURE-01Brace Model:
SURE-02,03,06, or 08
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Sure Step Comprehensive AFO Series Order Form A3417
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Solid Ankle - Rigid (SURE-09)
Bill To
1
Company
Account Number
Contact Person
Address
City/State/Province, Zip Postal Country
Phone
Purchase Order Number
Fax
Ship to (if different than bill to information)
Name
Address
City/State/Province, Zip Postal Country
Phone Fax
Next Day 2nd Day* GroundShip Method
2
................................................................................
FREE for your next order!
3
With each shipment, Trulife provides a full-calf (Bermuda) casting sock FREE of charge. Please specify the desired size. If size is not specified, size medium will be sent.
Medium Large X-Large None at this time
Important: Please carefully complete all fields. Incomplete information may result in delayed processing of your order.
*Standard Shipping is 2nd Day at Ground Rate
• Limits plantar flexion• Allows limited dorsiflexion• Varus/Valgus ankle stability• Dorsiflexion weakness
Solid Ankle - Flexible (SURE-10)
• Provides dynamic dorsiflexion• Provides controlled plantar flexion• Controls posterior migration of the tibia• Medial/lateral ankle stability
90° Plantar Flexion Stop (SURE-11)• Provides dynamic dorsiflexion• Controls moderate degree of knee hyperextension• Medial/lateral stability of ankle• Allows smooth plantar flexion from initial heel
contact to foot flat increasing knee stabilitywith presence of mild weakness of quads
Dorsiflexion Assist (SURE-12)
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• Triplanar ankle / foot motion control• Medial / lateral ankle stability• Post-operative support / protection• Added knee stability during stance• Mild knee hyperextension control
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Sure Step Comprehensive AFO Series Order Form
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Patient Information (Confidentially and securely maintained)
Name
Date
Occupation
Age
Left
Diagnosis
Activities
Sex Height Weight
Brace Side:
Right
Bilateral
Standard (E.V.A.)Top Cover:
Implus*
Spenco*
Add Poron Cushion To Extension*
Diabetic* (Plastazote / poron)
To Mets (Standard)Length Of Plastic Distally:
To Sulcus
To Toes
Heel lift*:_______________mmAdditions / Accommodations:
Add high flange to 1st ray
Add lateral flange to 5th ray (Use with abductionforefoot, do not use with lateral ankle instability)Orthotic plate accommodation* (Mark location on cast)
Navicular*
Styloid 5th met*
Other:_________________
Forefoot extension accommodation location*(Please mark on cast and on diagrams special instructions)
Minimum (Snug fit, no forgiveness)Arch Fill (Determines fit of orthotic of foot):
Standard (Close conformity, some forgiveness)
Maximum (Very forgiving)
According to cast (Standard)Cast Correction Instinsic Posting*:
None (Leave positive ‘as is’)
According to measurement belowLeft: _____ Varus:_____ Valgus:_____ Right:_____ Varus:_____ Valgus:_____
A cast mold of the patient’s limb should be taken in a non-weight bearing position with the foot and calf relationship at 90°. The patient’s foot can be placed on a soft foam cushion after it is cast. Position the footand ankle in the desired position of the finished orthosis. A foot-board may be used if desired (no Webril).Indicate all bony landmarks with indelible pencil.
A Bermuda cast must be used for these orthoses.
Casting Procedure:
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Special Instructions:
2 DegreesMedial Heel Skive:
4 Degrees
6 Degrees
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Add Instep Strap Additional Straps*:
Add Varus Corrective Strap
Add Valgus Corrective Strap
Send cast and order form to:Trulife Custom Sure Step Lab 26296 Twelve Trees Lane NW Poulsbo, WA 98370
SURE-09Brace Type:
SURE-10
SURE-11
SURE-12
Diameters Lengths Circumference
90°
Ankle MLForefoot
ML
*Additional charges may apply. See price sheet.
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Sure Step Neuropathic CROW Boot Order Form A3416
The Neuropathic CROW is a custom molded boot designed to off load the foot in a similar fashion to a total contact cast (TCC). It is essential for diabetic foot maintenance, the off-loading of foot ulcers, unstable Charcot foot/ankle, and post surgical protection and transition following foot/ankle reconstruction. This model provides a total contact interface, pretibial shell, and rocker bottom.
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Neuropathic CROW Boot
Bill To
1
Company
Account Number
Contact Person
Address
City/State/Province, Zip Postal Country
Phone
Purchase Order Number
Fax
Ship to (if different than bill to information)
Name
Address
City/State/Province, Zip Postal Country
Phone Fax
Next Day 2nd Day* GroundShip Method
2
................................................................................
FREE for your next order!
3
With each shipment, Trulife provides a Bermuda casting sock free of charge. Please specify the desired size. If size is not specified, size medium will be sent.
Medium Large X-Large None at this time
Important: Please carefully complete all fields. Incomplete information may result in delayed processing of your order.
*Standard Shipping is 2nd Day at Ground Rate
AFO.qxd 5/2/07 1:45 PM Page 23
Sure Step Neuropathic CROW Boot Order Form
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Patient Information (Confidentially and securely maintained)
Name
Date
Occupation
Age
Left
Diagnosis
Activities
Sex Height Weight
Brace Side:
Right
Bilateral
A cast mold of the patient’s limb should be taken in a non-weightbearing position with the foot and calf relationship at 90°. The patient’s foot can be placed on a soft foam cushion after it is cast. Position the foot and ankle in the desired position of the finished orthosis. A foot-board may be used if desired (no Webril).Foot measurements should be taken partially weight bearing withtoes fully extended. Add 1/2 to 3/4 inch to the patient’s full footmeasurements for the finished length.
• Indicate all bony landmarks with indelible pencil.• All measurements must be taken.• A Bermuda cast must be used for these orthoses.• A foot-board may be used if desired.
Note: Cast should be taken in the A.M. to accommodate for the leastamount of edema if possible.
Casting Procedure:
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Special Instructions:
*Additional charges may apply. See price sheet.
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Additional Plastizote Pad*Additions/Accommodations:
Other:_________________
Send cast and order form to:Trulife Custom Sure Step Lab 26296 Twelve Trees Lane NW Poulsbo, WA 98370
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Diameters Lengths Circumferences
90°
Ankle MLForefoot
ML
BlackColor:
Grey
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Rainier Boot Order Form A3394
The Rainier Boot offers the highest degree of biomechanical tri-planar control with durablepolypropylene reinforced ankle/foot structural shell. Made of all natural leathers, moldedclosed cell foam, and soft leather inner liner, the Rainier boot is designed for patient comfort.
The Rainier Boot is an excellent choice as a custom molded total contact AFO for treatmentmanagement protocols for posterior tibial tendon dysfunction, degenerative joint disease,Charcot foot, severe ankle abnormalities/instabilities, delayed union of ankle foot fusions,fractures, high sprains, and other ankle injuries.
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Rainier Boot
Bill To
1
Company
Account Number
Contact Person
Address
City/State/Province, Zip Postal Country
Phone
Purchase Order Number
Fax
Ship to (if different than bill to information)
Name
Address
City/State/Province, Zip Postal Country
Phone Fax
Next Day 2nd Day* GroundShip Method
2................................................................................
FREE for your next order!
3
With each shipment, Trulife provides a mid-calf casting sock free of charge. Please specify the desired size.
Medium Large X-Large None at this time
Important: Please carefully complete all fields. Incomplete information may result in delayed processing of your order.
*Standard Shipping is 2nd Day at Ground Rate
AFO.qxd 5/2/07 1:45 PM Page 25
Rainier Boot Order Form
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................................................................................
Patient Information (Confidentially and securely maintained)
Name
Date
Occupation
Age
Left
Diagnosis
Activities
Sex Height Weight
Brace Side:
Right
Bilateral
Additional Boot Information:Exterior Leather Color
Black Brown
Additional Notes:
Diameters Lengths Circumference
Overall Boot Height5 Inch 9 Inch
• 9" or 5" overall height (5" only available with laces)• Soft molded leather inner shell• Natural molded leather outer shell• Light-weight plastic structural shell• Padded 1/8” closed cell foam• Standard metatarsal length foot plate• Standard lace with one velcro closure
Standard Specifications:
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9 inch
5 inch
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Lengths
Additional Patient Information:Foot/Ankle Condition:
Flexible Rigid or Fused
Pathology:PTTD Trauma DJD Other:_______________________
Send cast and order form to:Trulife Custom Sure Step Lab 26296 Twelve Trees Lane NW Poulsbo, WA 98370
Cast Mold Information:Important Note: It is absolutely necessary that the casts be taken with the foot and ankle at 90° to avoid anyadditional lab cast correction charges. Additional charges and delays may result if cast correction is necessary.
For best results, cast patient during the morning hours, semi-weight bearing and frontal plane neutral, avoiding excessive pronation/supination. This is an accommodative cast if deformities are present.
NOTE: A Mid-Leg to Above-Calf casting sock must be used.
90°
Ankle MLForefoot
ML
OtherLaces Velcro (9 Inch only)
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