Right
5513 West Sligh Ave, Tampa FL 33634
Phone: 800-919-3668 Fax: 888-484-5927
Email: email@kineticresearch.com
Prefabricated AFO
Order Form
Company Information:
Date:_____________ PO#:______________
Company:____________________________
Billing address:________________________
______________________________________
Shipping address:_____________________
______________________________________
Adult Size: Pediatric Size:
Extra Small
Extra Small
Small
Small
Medium
Medium
Large
Extra Large
Large
Extra Large
Footplate Type:
Pre-cut
Shipping:
Ground
3-Day Next Day PM
2-Day Next Day AM
Form revised September 2019
For measurements please visit our website
at www.kineticresearch.com
Strut:
Lateral
Medial
Noodle AFO:
Left
Cuff:
(PDAC L1951)
T-Strap*:
*Additional Charges Apply
www.kineticresearch.com
Patient Information:
Patient name:__________________________
Shoe Size: _______
Ship to meet due date:_______
Posterior Classic
Posterior Hemi-Spiral
Anterior TA
(PDAC L1932)
Oversized
Nano AFO:
Left
Cuff:
Posterior
Anterior
Strut:
Lateral
Medial
Adult Size:Size
Extra Small
Small
Medium
Large
Extra Large
Options:
Pre-Tibial Shell*:
If left unchecked, strut will default to lateral. Incomplete forms will not be processed.
(PDAC L1951)
(PDAC L1932)
Right
(PDAC L1951)
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