Patient Name: ___________________________________________________________

Dx: ___________________________________________________________________

Height: ___________________________ Weight: _____________________________

c Right c Left c Bilateral

Company Name: _____________________________________ Contact Person: __________________________________________

P.O. : ______________________________________________ Phone: _________________________________________________

Email: ______________________________________________________________________________________________________

Bill my account: c Arizona AFO c Langer c TOG c SafeStep

Shipping and Billing Address: ___________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Arizona Mezzo™ Selection:

c Standard c Partial Foot

Brace Option:Color :

c Black c Sand c Brown c White

Footplate:

________ Proximal to Mets (Standard) ________ Distal to Mets ________ Full Length

Closure:

________ Laces (Standard) ________ Laces with Extended Lateral Lace Stay (Abduction Control)

Heel Post:

________ Extrinsic Post to Neutral (Standard) ________ Extrinsic Medial Post

Cast Modifications:

________ No Correction ________ Correct to 90°

________ Correct Forefoot Alignment ________ Correct Hindfoot Alignment

Additional Padding:

________ As Marked on Cast Other: ________________________

C.Ped Name: __________________________________________________________________

TM

Arizona Mezzo™ Order Form