5513 West Sligh Ave, Tampa FL 33634
Phone: 800-919-3668 Fax: 888-484-5927
Email: email@kineticresearch.com
Build-to-Order Noodle
Order Form
Practitioner Information:
Date:_____________ PO#:______________
Practitioner:___________________________
Company:____________________________
Billing Address:________________________
______________________________________
______________________________________
Shipping Address:_____________________
______________________________________
______________________________________
Due Date:____________________________
Patient Information:
Patient Name:________________________
Age:_____ Height:______ Weight:_______
Gender: Male Female
Shoe Size:_____________
Activity Level:_________________________
Pathology:____________________________
______________________________________
______________________________________
Form revised August 2019
Left Right
Shipping:
Ground
3-Day
2-Day
Next Day PM
Next Day AM
Footplate:
Flexible
Normal
Stiff
Extra Stiff
Flexibility:
Strut:
Flexible
Normal
Stiff
Extra Stiff
Strut:
Lateral
Medial
Black
Caucasian*
Fabric*:__________________
Footplate Length:_____________________
Proximal Shell(cuff) Height:____________
Noodle AFO Style:
Cuff: Posterior Classic
Posterior Hemi-spiral
Anterior TA
(PDAC L1951)
(PDAC L1932)
Pretibial Shell*:
Color:
T-Strap*:
* Additional Charges Apply
www.kineticresearch.com
Unchecked items will default to our standard fabrication in bold underline.
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