Custom Order Form
Ossur GII XT Unloader / Extreme Knee Orthosis
Australian Orthotic Technologies Pty Ltd
15/ 114 Merrindale Drv, Croydon VIC 3136 Australia
PO Box 142, Croydon VIC 3136 Australia
Telephone: (03) 8761 6408
Facsimile: (03) 9761 6067
Order Information
Date
Sender
Order No.
Address
Patient Information
Patient Name
Diagnosis
Height
Age
Weight
Sex M / F (circle one)
Deformity (circle one) Varus / Valgus
Degree of deformity
Date of Recent Knee Surgery
Correctable ?
Notes / Activities
Hyperextension
Anterior Draw
Posterior Draw
Rotatory Instability
(anteromedial / anterolateral)
Orthosis Specifications
Left / Right
Unicompartmental OA (circle one)
Medial / Lateral
Extension stop (circle one)
0˚ / 5˚ / 10˚
Shell Colours (circle one)
Standard - Stealth (matt black)
Other (circle one - additional cost applies, allow additional 1 week)
-
Shell Liners (circle one)
Standard - Doe skin thigh
/ Evazote calf
Ocean Blue, Violet, Desert Sand, Glistening Gold, Evergreen,
Striking Silver, Carbon Eclipse, Candy Apple Red
Other (circle one - additional cost may apply, allow additional 1 week)
Shark skin
Doe skin thigh & calf
Evazote thigh & calf
Other requirements (please specify)
Casting Instructions:
Remember: The accuracy of the cast determines the quality of the orthosis fit
1. Make a cylinder cast 30cm (12”) proximal and 30cm (12”) distal to mid patella, using plaster or fibreglass. Clearly mark the
patella, fibula head, joint line and tibial crest.
2. Patient should be cast in non-weightbearing, uncorrected with the knee in full extension and ankle at 90˚.
3. Use stockinette only, do not use cast padding.