ToeOFF® Family of Products Warranty Registration
* these values have to be filled out.
Company Information
Name of Facility
*
Address
*
City
*
Zip
*
Phone
Fax
Country
*
---
USA States
USA Territories
Canada
State/Province/Territory
*
Attending Orthotist
Purchased from
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Allard USA
Cascade
Knit-Rite
OrtoPed
Pel Supply
SPS
P.O.#
Product information
* (Left or right extremity has to be filled out)
Affected extremity, Serial Number, & Size
Left
Serial No*
Size
---
Unknown
XSmall
Small
Medium
Large
XLarge
Right
Serial No*
Size
---
Unknown
XSmall
Small
Medium
Large
XLarge
*
(Located on inside of the anterior support – alpha character followed by 4 – 6 numbers)
Date of fitting
Date
*
Patient information
Patient Name or I.D.#
Height
*
---
Unknown
up to 5'
5 - 5 1/2'
5 1/2 - 6'
6- 6 1/2'
6 1/2 - 7'
>7'
Weight
*
---
Unknown
up to 100 lb.
100-150 lb.
150-200 lb.
200-250 lb.
250-300 lb.
300-350 lb.
>350 lb.
Sex
*
---
Unknown
Male
Female
Cause of Footdrop
*
---
Unknown
Cerebral Palsy
Charcot Marie Tooth
CVA
Herniated Disc
Hemiplegia
Lower Extremity Trauma
Multiple Sclerosis
Muscular Dystrophy
Myelomeningocele
Neuropathy
Other
Partial Foot Amputation
Post Spinal Surgery Complication
Post-Polio
Spinal Cord Injury
Year of onset
---
Unknown
0 - 1 years
1 - 3 years
4 - 8 years
More then 8 years
Foot Condition
Flaccid
Spastic
Supinated
Pronated
Gait Pattern
Genu Recurvatum
Crouch Gait
Shoe Size
Women
---
Unknown
4
5
6
7
8
9
10
12
Men
---
Unknown
4
5
6
7
8
9
10
11
12
13
14
Children
---
Unknown
9.5
10
10.5
11
11.5
12
12.5
13
13.5
1
1.5
2
2.5
3
3.5
4
Activity Level
*
---
Unknown
Low
Average
High
Customization Info
Padding
*
---
Unknown
Custom
SoftKIT/ComfortKIT
None (not recommended)
Modifications
Trimming
None
Height of Tibia Plate
At Toe End
At heel end
Calf Wings
Orthotic additions
Metatarsal Post
Medial Post
Intrinsic
Extrinsic
Lateral Post
Intrinsic
Extrinsic
Heel Wedge
Intrinsic
Extrinsic
No Modifications