KiddieGAIT Warranty Registration
* these values have to be filled out.
Company Information
Name of Facility
Address *
City *
Zip *
Phone
Fax
Country *
State/Province/Territory *
Attending Orthotist
Purchased from
P.O.#
Product information * (Left or right extremity has to be filled out)
Affected extremity, Serial Number, & Size
Left Serial No* Size
Right Serial No* Size
* (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.#
Age
Height *
Weight *
Sex *
Cause of Footdrop*

Year of onset
 
Foot Condition
Flaccid
Spastic
Supinated
Pronated
Other
 
Gait Pattern
Genu Recurvatum
Crouch Gait
Uses Walker/Cane
Toe-walker
Non-Ambulatory
 
Shoe Size
 
Activity Level *
 
Customization Info
Padding *
 

Modifications
Trimming
None
Height of Tibia Plate
At Toe End
At heel end
Calf Wings
 
Orthotic additions
Prefabricated foot
orthotic insole
Custom foot orthotic
UCBL
SMO
Other 
     
Metatarsal Post Intrinsic
  Extrinsic
     
Medial Post Intrinsic
  Extrinsic
     
Lateral Post Intrinsic
  Extrinsic
     
Heel Wedge Intrinsic
  Extrinsic
   
None