No Casting
Today’s Date: ____________________________________
Cascade Dafo, Inc.
1360 Sunset Ave, Ferndale, WA 98248
ph 800.848.7332 intl +1 360 543 9306
fax 855.543.0092 www.cascadedafo.com
Thank you!
Patient
Last name:
First name:
Male
Female
Birth date:
Parent or Guardian:
Practitioner
Name: Title:
Facility:
Street Address:
City: State: Zip:
Phone:
Email:
Payment Options
Facility Billing (Practitioner)
–OR–
Account Name or #:
P.O. N
o
:
CC on fi le
Insurance Billing (Parent / Guardian / Practitioner)
–OR–
UCAN N
o
:
Direct Purchase (Parent / Guardian)
Check attached
Credit Card:
Visa
MasterCard
AMEX
Discover
Cardholder’s Phone:
Credit Card No:
Exact name on card:
Exp. Date: V-code:
Billing Information
Billing Name:
Facility:
Street Address:
City: State: Zip:
Phone:
Email:
Shipping
Same as billing information. –OR–
Shipping contact name:
Street Address:
City: State: Zip:
Phone:
© 2021 Cascade Dafo, Inc. All rights reserved.
2
Order PattiBob Rev. 5 (May 2021)
3.00 – 12.25 in.
(0.25 in. increments)
Size | Options
Sizing
Pair
Left
Right
Length: _________________________
Width:
Wide
Narrow
Fill
Arches?
Soft Foam
(additional charge)
Medium Foam
(additional charge)
Flatten
Toe Rise?
Yes
No
-or-
1 layer of plastic
1 layer
of foam
Semi-rigid partial
heel cup
Toe rise contour
under toes 2–5
Comments
Moderate support shoe insert
PattiBob
®
TO ORDER—fill this out, print, fax/mail to Cascade; -or- fill this out, save, email to customersupport@dafo.com
