Custom order form - Allard International

Instructions for how to order a ToeOFF/BlueRocker Customand Custom AFO Standard/Rigid.Carefully read this instruction sheet before use!ToeOFF/BlueRocker-Custom is CE-marked products and follows our standard ToeOFF-Family warrantyrules as long as no “non CE-marked” shape and/or property has been ordered. If shape and/or property in the right column have been chosen the product becomes “special made” and will benamed “Custom AFO Standard or Rigid, and the responsibility for the product falls on the prescriber.For Custom AFO Standard or Rigid we guarantee that the product has been produced according toGMP (Good Manufacturing Practice) with a warranty time of 6 month. The warranty does not includefunction or effects on durability created through the composition of properties.Intended Use: ToeOFF is intended to support a foot when the ability to actively dorsiflex is reducedor completely lost. BlueRocker is intended to support a foot when the ability to actively dorsiflex isreduced or completely lost and when extra stability is needed to support the ankle joint. BlueRockeris primarily developed to meet the extra need for stability with patients that needs dosiflex assist onboth left and right limb.Indications: Stroke, Multiple sclerosis, Post polio syndrome, Muscular dystrophy, Spinal cord injuries,Traumatic brain injuries, Guillian-Barre syndrome, Chacot-Marie-Tooth, Myelomeningocele or Cerebralpalsy. ToeOFF and BlueRocker are preferred when footdrop is combined with ankle instability. Thesetwo orthoses can also be used for partial foot amputations, most proximal level is Chopart.Kontraindikationer: ToeOFF and BlueRocker should not be used by patients with leg ulcers or in caseswhere moderate to severe oedema is present, or where moderate or severe foot deformities areevident. ToeOFF and BlueRocker should not be used when severe spasticity is present. The definition forspasticity is described in ToeOFF Family Clinical Manual.Special precautions should always be taken for patients with reduced feelingin the lower extremities. Daily monitoring of skin condition is advised.• The ordering form on the following pages is divided into different sections.• The Basic information on the first page must always be filled out.• The additional information should be filled out for products that do not followthe standard product.• Shapes and properties in the left column will keep the product as a CE-marked product.I any shapes/properties in the right hand column are chosen the product responsibility ismoved to the prescriber (outside of the CE-marking).• The same demands for fitting and adjustments should be followed as for a regular ToeOFFor BlueRocker. Read the instructions in the ToeOFF-Family Clinical Manual.Patent no.: ToeOFF, ToeOFF Short, ToeOFF Fantasy, ToeOFF NFR, BlueRocker, BlueRocker NFR, KiddieGAIT, KiddieGAITNFR AU736950, BE1005297, BE1114626, DK1005297, DK1114626, FI1005297, FI1114626, FR1005297,FR1114626, IE1005297, IE1114626, IT1005297, IT1114626, CA2279225, CNZL97181689.1, NL1005297,NL1114626, NO313656, PL194247, CH1005297, CH1114626, ES1005297, ES1114626, GB1005297, GB1114626,SE1005297, SE1114626, DE69709184.8-08 DE69732541.5-08, US5897515, ATE210417, ATE289187 ©www.allardint.comTel +46 42 25 27 00Fax +46 42 25 27 25ALLARD INTERNATIONALc/o Camp Scandinavia ABKarbingatan 38SE-254 67 Helsingborg SWEDENmail.sweden@camp.se

Basic information for ordering a ToeOFF/BlueRocker Customand Custom AFO Standard/Rigid.This page should always be filled out and sent in with the order.Date:Purchase no:Orthotist:Phone:E-mail:Address:This order is made from: Scanning Cast (positive) Cast (negative)MeasurementStandard ToeOFF/BlueRockerScanningen/cast is with insoles: YES NO(When patient is using corrective (varus/valgus) insoles. Only possible for order by Scanning or Cast).What is the main purpose of the order:Patient ID (same ID as for cast or file):Diagnosis:Patient is currently using a ToeOFF/BlueRocker in size:Length: Weight: Foot length: Lower leg height(heel - knee centre):Plantar/dorsiflexion: Neutral can be achieved in active/passive ankle joint motion(10 o dorsiflexion) If NO, the product is not CE-approved: YES NOPartial foot amputation: YES NOActivity level:Short distances indoor with or without assistanceShort distances indoor and outdoorManage daily activities without problemsWalk longer distances without problemsHigh activity, sports on a daily basisFrom the information above a ToeOFF/ BlueRocker will be manufactured were the footlength, foot width, heel height, stiffness and sideway stability is equal to a standard product.ToeOFF: Left RightBlueRocker: Left RightFantasy-yta: Ivory Black Dark Blue PurpleAdd Interface: SoftKIT, Black SoftKIT, Beige ComfortKITSoftSHELL, Beige SoftSHELL, Brown NonPage 3 / 5www.allardint.comTel +46 42 25 27 00Fax +46 42 25 27 25ALLARD INTERNATIONALc/o Camp Scandinavia ABKarbingatan 38SE-254 67 Helsingborg SWEDENmail.sweden@camp.se

On this page the characteristics of the product can bechanged.ToeOFF/BlueRocker CustomCE-Registered productBasic costFootplate length: mm(5mm intervall from 190 - 310 mm)Heel height (effective toelift is always 15mm)Custom AFO standard & RigidNon CE-Registered productBasic costOff-load for high instepI.e when there is a cavus/varus deformation.(Only for order from scanning or cast).As a standrad ToeOFF/BlueRocker (15mm)Heel height: 5mm 10mm20mm 25mmToeOFF/BlueRocker CustomCE-Registered productAdditional CostFootplate width:Relief prominenses:Equal to 1 sz smallerEqual to 1 sz largerTibia crest: 3mm 5mmmmIndidvidual relief : mm(Only for order from scanning or cast)Stiffness A-P:Less stiff, compared to ~ 1 sz smallerLess stiff, compared to ~ 2 sz smallerMore stiff, compared to ~ 1 sz largerMore stiff, compared to ~ 2 sz largerSideways stability M-L:Less stiff, compared to ~ 1 sz smallerLess stiff, compared to ~ 2 sz smallerMore stiff, compared to ~ 1 sz largerMore stiff, compared to ~ 2 sz largerCustom AFO standard & RigidNon CE-Registered productAdditional CostHeel height > 25 mmmmChange of Toe height and Heel height5mm & 5 mm Toe- and heel height10mm & 10 mm Toe- and heel heightChange of stiffness for heel / toe partStandard toe - less stiff heel,compared to ~ 1 sz smallerStandard toe - stiffer heel,compared to ~ 1 sz largerStandard heel - less stiff toe,compared to ~ 1 sz smallerStandard heel - stiffer toe,compared to ~ 1 sz largerNOTE! It is not possible to combine the stiffness in A-P with a softer M-L.When a less rigid product is required we recommend to carefully check that this notaffect spasticity if present.Page 4 / 5www.allardint.comTel +46 42 25 27 00Fax +46 42 25 27 25ALLARD INTERNATIONALc/o Camp Scandinavia ABKarbingatan 38SE-254 67 Helsingborg SWEDENmail.sweden@camp.se

On this page it is possible to order a product from onlymeasurements. The information on page 3 and 4 mustalso be completed and sent with the order.Patient ID:Side: Left RightCircumf.M-L40 cm from floormmmm35 cm from floormmmm30 cm from floormmmm25 cm from floormmmm20 cm from floormmmm15 cm from floor10 cm from floormmmmmmmmFoot length =mmPlace a 10 cm long strip posterior on calf muscle. This isused as a referrence for scaling in the computer. Take adigital photo from behind at 2 meters distance and sendwith the PO.Page 5 / 5www.allardint.comTel +46 42 25 27 00Fax +46 42 25 27 25ALLARD INTERNATIONALc/o Camp Scandinavia ABKarbingatan 38SE-254 67 Helsingborg SWEDENmail.sweden@camp.se