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Y Date: MEASUREMENTS: Inches Centimeters Warranty Information Diagnostic Check Orthosis (DCO) Yes No I understand this/these device(s) will not be covered by the fit warranty if a diagnostic check orthosis (DCO) is not ordered. (If no, please sign) Signature Date Side RIGHT LEG LEFT LEG Please use separate form for each leg if bilateral Type of Orthosis AFO PTBO KAFO Modular Style IRD ERD IRD/ERD Neutral Skeletal Phone:.

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