Doctor & Patient Information

RICHIE BRACE PRESCRIPTION FORM

DOCTOR INFORMATION

6299 Guion Road Doctor Name: ______Indianapolis, IN 46268 Address: City: ______State:______Zip:______

1-800-444-3632 Fax:1-800-233-2280 ACCT#: www.AOLabs.com Ph: Fax: Email: PATIENT INFORMATION OPTIONAL

Please fax or mail completed Patient Name______Male Female order form to above information.

Age:______Height:______Weight:______Shoe Size:______OTC RICHIE BRACE® PRESCRIPTION  OTC RICHIE BRACE® (Ordering for patient):

 Left  Full Flexion □ Dynamic Assist  Right  Permanent Fixed  Bilateral SIZES FOR OTC RICHIE BRACE®:  X-Small (Women shoe sizes 4-6)  Small (Men shoe size 5-7 & Women shoe sizes 7-8)  Medium (Men shoe size 8-11 & Women shoe sizes 9-10)  Large (Men shoe size 11-13 & Women shoe sizes 11+)  X-Large (Men shoe size 14)

OTC RICHIE BRACE® (Ordering for Stock in office)

SIZES FOR OTC RICHIE BRACE®: X- Small (Womens size 4-6) Small (Men shoe size 5-7 & Women shoe sizes 7-8) Medium (Men shoe size 8-11 & Women shoe sizes 9-10) Large (Men shoe size 11-13 & Women shoe sizes 11+) X-Large (Men shoe size 14+)

Please indicate how many braces ordered before each size  Left Full Flexion Left Permanent Fixed  Right Full Flexion  Right Permanent Fixed

 ______X-small  ______X-small  ______X-small  ______X-small  ______Small  ______Small  ______Small  ______Small  ______Medium  ______Medium  ______Medium  ______Medium  ______Large  ______Large  ______Large  ______Large  ______X-Large  ______X-Large  ______X-Large  ______X-Large

Full flexion/Perm fix OTC Clinical Indications: Suggested CPT code L 1906 Decription:  Acute Grade ll and lll Ankle Sprain  Syndesmosis Sprain (High Ankle Dynamic OTC: Semi rigid ankle stirrup with a Sprain) Suggested CPT Code L 1971  Midfoot Sprain Dynamic Assist add pre-form orthotic footplate.  Peroneal, Extensor & Posterior Tibial Tendonitis L2210 X 2  Preliminary treatment before custom Richie Brace AFO Therapy Add KX behind all L codes