Thank you! © 2019 Cascade Dafo, Inc. All rights reserved. 58 Cascade Dafo, Inc. 1360 Sunset Ave, Ferndale, WA 98248 ph 800.848.7332 intl +00 1 360 543 9306 fax 855.543.0092 www.cascadedafo.com K3 Knee Brace Hinged knee extension orthosis Special Instructions Order HK3 Rev.01 (Apr 2019) DAFO ® Patient Last name: First: c Male c Female Birth date: / / c Bilateral c Left only c Right only Practitioner Name: Title: Facility: Street address: City: State: Zip: Email: Phone: Billing c Cascade P&O is billing the patient’s insurance. –OR– —UCAN N o : c Billing info is the same as practitioner facility. –OR– c Billing facility: Street address: City: State: Zip: P.O. N o : Shipping c Shipping info is the same as practitioner facility. –OR– Shipping contact name: Street address: City: State: Zip: Knee Pad and Strap Velcro Anterior Straps Outer Frame MEDIAL (Left) Velcro Anterior Strap LATERAL (Left) Adjustable Rachet Joint Soft Proximal Edge Soft Distal Edge Soft Foam Liner Liner • Straps • Transfer Liner Color: c White c Black Standard Strap Color: c White Standard c Other: Transfer Pattern: (Additional cost per brace) c No Transfer Standard c Pattern: ______________________________ c Provide Own Pattern Right Leg Left Leg Measurement Information Order must include Cast or scan that spans from near groin to malleolus.