K3 - daniz53y71u1s.cloudfront.net · K3 Knee Brace Hinged knee extension orthosis Special...
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Thank you! © 2019 Cascade Dafo, Inc. All rights reserved. 58 Cascade Dafo, Inc. 1360 Sunset Ave, Ferndale, WA 98248 ph 800.848.7332 intl +00 1 360 543 9306 fax 855.543.0092 www.cascadedafo.com K3 Knee Brace Hinged knee extension orthosis Special Instructions Order HK3 Rev.01 (Apr 2019) DAFO ® Patient Last name: First: c Male c Female Birth date: / / c Bilateral c Left only c Right only Practitioner Name: Title: Facility: Street address: City: State: Zip: Email: Phone: Billing c Cascade P&O is billing the patient’s insurance. –OR– —UCAN N o : c Billing info is the same as practitioner facility. –OR– c Billing facility: Street address: City: State: Zip: P.O. N o : Shipping c Shipping info is the same as practitioner facility. –OR– Shipping contact name: Street address: City: State: Zip: Knee Pad and Strap Velcro Anterior Straps Outer Frame MEDIAL (Left) Velcro Anterior Strap LATERAL (Left) Adjustable Rachet Joint Soft Proximal Edge Soft Distal Edge Soft Foam Liner Liner • Straps • Transfer Liner Color: c White c Black Standard Strap Color: c White Standard c Other: Transfer Pattern: (Additional cost per brace) c No Transfer Standard c Pattern: ______________________________ c Provide Own Pattern Right Leg Left Leg Measurement Information Order must include Cast or scan that spans from near groin to malleolus.
Transcript of K3 - daniz53y71u1s.cloudfront.net · K3 Knee Brace Hinged knee extension orthosis Special...
Thank you!© 2019 Cascade Dafo, Inc. All rights reserved. 58
Cascade Dafo, Inc.1360 Sunset Ave, Ferndale, WA 98248ph 800.848.7332 intl +00 1 360 543 9306fax 855.543.0092 www.cascadedafo.com
K3 Knee BraceHinged knee extension orthosis
Special Instructions
Order HK3 Rev.01 (Apr 2019)
DA
FO®
Pat
ient
Last name:
First: c Male c Female
Birth date: / / c Bilateral c Left only c Right only
Pra
ctit
ione
r
Name: Title:
Facility:
Street address:
City: State: Zip: Email: Phone:
Bill
ing
c Cascade P&O is billing the patient’s insurance. –OR–
—UCAN No :
c Billing info is the same as practitioner facility. –OR–
c Billing facility:
Street address:
City: State: Zip:
P.O. No :
Shi
ppin
g
c Shipping info is the same as practitioner facility. –OR–
Shipping contact name:
Street address:
City: State: Zip:
Knee Pad and Strap
VelcroAnteriorStraps
Outer Frame
MEDIAL (Left)
VelcroAnteriorStrap
LATERAL (Left)
Adjustable RachetJoint
Soft Proximal
Edge
Soft Distal Edge
Soft FoamLiner
Liner • Straps • Transfer
Liner Color: c White c Black
Standard
StrapColor: c White
Standard c Other:
TransferPattern:
(Additional cost per brace)
c No Transfer Standard
c Pattern: ______________________________ c Provide Own Pattern
Right Leg Left Leg
Measurement InformationOrder must include Cast or scan that spans from near groin to malleolus.
