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1/4 Black polypropylene Carbon ber specify choice below Black carbon laminate Beige laminate Light brown laminate Measurement/Casting ADDITIONS LAB USE ONLY Intake Date Negative heel MATERIALS INNER MOLDED BOOT 1/2 rm pu standard thickness Dorsal toe cover ALL dacron straps Medial out are Rocker sole/lateral wedge Leather lacer Lateral out are Pad tibial shell Mark Wound Position Fibular height Finished AFO height Shipped Date Serial Number Tracking Number Technician 1570 Beam Avenue Ste. 100 Maplewood MN 55109 p 1-855-4TILTEC 484-5832 f 651-748-4574 e info tillgestechnologies. com w www. MINNESOTA BOOT CUSTOM AFO ORDER FORM Order Date Date Needed PO BILLING INFORMATION Facility Contact Name Address City State Phone Fax Email SHIPPING INFORMATION Zip Same as Billing SHIPPING INSTRUCTIONS Next Day Air 2nd Day Air 3rd Day Air Ground Local / Hand Delivery PATIENT INFORMATION Last Name Male First Name Female Age Weight LT RT BIL Diagnosis Special Instructions FABRICATION INSTRUCTIONS SOLE STYLE TYPE OF AFO Rocker sole standard Solid AFO Forefoot / midfoot unloading Unloader AFO Midfoot / hindfoot unloading Rocker sole/medial wedge CAST CORRECTIONS Leave as casted Correct to 90 degrees in shoe Extra 1/2 at heel Extra 1/2 over plantar surface Extra 1/2 rm crepe at heel 225 lbs. 1/4 Black polypropylene Carbon ber specify choice below Black carbon laminate Beige laminate Light brown laminate Measurement/Casting ADDITIONS LAB USE ONLY Intake Date Negative heel MATERIALS INNER MOLDED BOOT 1/2 rm pu standard thickness Dorsal toe cover ALL dacron straps Medial out are Rocker sole/lateral wedge Leather lacer Lateral out are Pad tibial shell Mark Wound Position Fibular height Finished AFO height Shipped Date Serial Number Tracking Number Technician 1570 Beam Avenue Ste.