Nexgear Tango adjustable stop-module | Nexgear Tango | Multifunction Ankle Joints | AFO - Ankle Foot Orthosis | Custom Orthotics | Orthotics | Ottobock CA Shop
Nexgear Tango Reaction-Spring strong | Nexgear Tango | Multifunction Ankle Joints | AFO - Ankle Foot Orthosis | Custom Orthotics | Orthotics | Ottobock US Shop
Nexgear Tango AFO iFab Order Form Account Information Date Account Number Bill to Phone Number Email Buyer PO Number Ship To Information Name Address City/State/Zip Phone Number Email Desired Delivery Date Please mail your completed Ottobock order form and a negative impression of the patient's limb to the address below. An Ottobock Fabrication Coordinator will contact you. Shipping Options UPS Next Day UPS Ground UPS 2-Day Other Once this form is complete, please send to Ottobock via fax or email. Order Quote Only Click to Email Form For clinical questions, call 800 328 4058. Patient Information Patient Name Side Left Side Right Side Special Instructions / Comments Patient Weight lbs. Pathology Fitting Stage Test Orthosis Definitive Orthosis All specifications and pricing are subject to change without notice. ©2022 Otto Bock HealthCare LP · 20280 · 02/2022 Fabrication Facility: 3820 West Great Lakes Drive, Salt Lake City, UT 84120 For more information please visit our web site at professionals.ottobockus.com Page 1/3 Phone: 800 328 4058 · Fax: 800 810 7994 Email: fabrication@ottobock.com Nexgear Tango AFO iFab Order Form 17AD100 Nexgear Tango Joint Selections If you selected 17AD100=16-T and 17AD100=20-T for the ankle joint, please select one of each of the following. If you selected another ankle joint, please disregard this section. If you have any questions, please contact clinical support. 1. Anterior Lateral Channel 2. Anterior Medial Channel 3. Posterior Lateral Channel 4. Posterior Medial Channel Free Motion Free Motion Free Motion Free Motion Stop Module Stop Module Stop Module Stop Module Spring Module Spring Module Spring Module Spring Module Reaction Module Firm Reaction Module Firm Reaction Module Firm Reaction Module Firm Reaction Module Extra Firm Reaction Module Extra Firm Reaction Module Extra Firm Reaction Module Extra Firm The 17AD100=MA-20 Mounting Adapter is required to use the 17AD100=16/20-T joint. Do you need a 17AD100=MA-20 Mounting Adapter? This is a specialty tool needed for an initial Nexgear Tango joint fitting. Yes, please include No, I already have one Additional tools you will need are an L-shaped T20 torx key and a torque wrench with a T30 bit. Nexgear Tango Selecting & Ordering 1 1.1 1 Joint Body pc(s) 17AD100=10 pc(s) 17AD100=12 pc(s) 17AD100=14 pc(s) 17AD100=16 pc(s) 17AD100=20 pc(s) 17AD100=10-T pc(s) 17AD100=12-T pc(s) 17AD100=14-T pc(s) 17AD100=16-T pc(s) 17AD100=20-T 1.1 Mounting Adapter (Specialty tool used to mount modules in joint body) pc(s) 17AD100A=MA-10 Must be purchased with first-time purchase of 17AD100=10/10-T pc(s) 17AD100A=MA-12 Must be purchased with first-time purchase of 17AD100=12/12-T pc(s) 17AD100A=MA-14 Must be purchased with first-time purchase of 17AD100=14/14-T pc(s) 17AD100A=MA-20 Must be purchased with first-time purchase of 17AD100=16/16-T and 17AD100=20/20-T 2 3 4 5 2 Lamination Bar pc(s) 17LS3=10 pc(s) 17LS3=12 pc(s) 17LS3=14 pc(s) 17LS3=16 pc(s) 17LS3=20 pc(s) 17LS3=10-T pc(s) 17LS3=12-T pc(s) 17LS3=14-T pc(s) 17LS3=16-T pc(s) 17LS3=20-T 3 Stirrup pc(s) 17SF100=OS-10 pc(s) 17SF100=OS-12 pc(s) 17SF100=OS-14 pc(s) 17SF100=OS-16 pc(s) 17SF100=OS-20 4 Stop Module pc(s) 17AD100A=AS-10 pc(s) 17AD100A=AS-12 pc(s) 17AD100A=AS-14 pc(s) 17AD100A=AS-16 pc(s) 17AD100A=AS-20 5 Spring Module pc(s) 17AD100A=LS-10 pc(s) 17AD100A=LS-12 pc(s) 17AD100A=LS-14 pc(s) 17AD100A=LS-16 pc(s) 17AD100A=LS-20 6 6A 6B 6 Reaction Module pc(s) 17AD100A=HS-10 pc(s) 17AD100A=HS-12 pc(s) 17AD100A=HS-14 pc(s) 17AD100A=HS-16 pc(s) 17AD100A=HS-20 Fabrication Facility: 3820 West Great Lakes Drive, Salt Lake City, UT 84120 For more information please visit our web site at professionals.ottobockus.com Page 2/3 6A Reaction Spring Strong 6B R eaction Spring Extra Strong pc(s) 17AD100A=HS-12-1 pc(s) 17AD100A=HS-14-1 pc(s) 17AD100A=HS-20-1 pc(s) 17AD100A=HS-12-2 pc(s) 17AD100A=HS-14-2 pc(s) 17AD100A=HS-20-2 Phone: 800 328 4058 · Fax: 800 810 7994 Email: fabrication@ottobock.com Nexgear Tango AFO iFab Order Form Standard AFO Configuration Includes: Pre-preg exterior frame, Anterior shell, Satin black finish, Dacron calf strap with chafe, One liner included *Any special requests outside of our standard AFO configuration can be written in the special instructions / comments section on first page. Add-On Options (additional charges apply) Padding Material Malleolus pad Microcel Puff Arch pad Bocklite 2mm 3mm Calf liner Other Anterior shell Full foot shell If used as corrective padding, additional L-Code applies: L2275 x1 Please check one: Varus correction Valgus correction Ankle Strap Dacron strap and chafe Hook-and-loop lay over ankle strap AFO Finish Black finish Custom sleeve (Fred's Legs) Specify Casting Instructions When casting for a dynamic AFO, accurate shoe heel height representation in the cast is critical and we recommend using a foot casting aid (part # 743A9) or equivalent. The line of progression is critical for placement of toe break in the fabrication and carbon layup of the foot section with the AFO. This line of progression is established in the impression with the patella and popliteal landmark, and should be noted if it is more than 7°. Please ensure the height of the impression is at or proximal to the patella to accurately model both landmarks. Make sure to end your wrap distal to the phalanges utilizing another roll of casting material, if necessary. The patient's thigh, knee, tibia, and foot must all be maintained in line of progression during casting. Your cast height has to be at least 1 cm higher than your finished orthosis height. We will not extend casts higher or fill in missing phalanges. Please make sure your cast removal strip is placed lateral to the proximal half of the tibial crest, and your model provides accurate representation of the patient's proximal tibial crest. Metric Measurements Only Heel height (standard is 5mm) mm Effective Heel Height Height of Heel Lift (if any) mm Metric Measurements Only Trim line height of AFO (standard is ~3cm below fib head) Ankle center line to bottom of heel Heel height Bottom of heel Fabrication Facility: 3820 West Great Lakes Drive, Salt Lake City, UT 84120 For more information please visit our web site at professionals.ottobockus.com Page 3/3 Phone: 800 328 4058 · Fax: 800 810 7994 Email: fabrication@ottobock.comAdobe PDF Library 16.0.5 Adobe InDesign 17.1 (Macintosh)