DatePatient InformationPatient Name *Patient Email *Patient Phone *Do you have a purchase code?YesNo(optional)What type of purchase code do you have?Influencer CodeDevice CodeShipping CodeInfluencer CodeYou won't get another chance to do this, so if you have an influencer code please enter it now!Device CodeYou won't get another chance to do this, so if you have a device code please enter it now!Shipping CodeYou won't get another chance to do this, so if you have a shipping code please enter it now!Provider InformationReferring Provider Name *Provider Email *Provider PhoneReferring Provider ZIP *0 / 5PrescriptionThe selections below should be determined by your provider.Diagnosis / ICD10PrecautionsOrthosis Style *Wrist Cock-up thin splint - $349Wrist Cock-up protective cast - $349Wrist Cock-up strength coated cast (recommended for athletes/durability/strength, comes in white only) - $449Hand-Based Thumb Spica/MP Block/Ulnar/Radial Gutter protective cast - $249Hand-Based Thumb Spica/MP Block/Ulnar/Radial Gutter strength coated cast (recommended for athletes/durability/strength, comes in white only) - $349Hand-Based Functional splint (comes in white only) - $249Forearm-Based Thumb Spica thin splint - $349Forearm-Based Thumb Spica protective cast - $349Forearm-Based Thumb Spica strength coated cast (recommended for athletes/durability/strength, comes in white only) - $449Forearm-Based MP Block/Ulnar/Radial Gutter protective cast - $399Forearm-Based MP Block/Ulnar/Radial Gutter strength coated cast (recommended for athletes/durability/strength, comes in white only) - $499Elbow protective cast - $449Long-arm protective cast - $549Ankle foot orthosis - Non-Weight Bearing - $449Ankle foot orthosis - Weight Bearing - $749Ankle foot orthosis - Weight Bearing (strength-coated, comes in white only) - $849Important Note:The turnaround time on the "Ankle Foot Orthosis - Weight Bearing" orthosis may be longer than other products.Digits *I (thumb)II (index finger)III (middle finger)IV (ring finger)V (pinky)Joints *MP (joint that connects the finger/thumb to the hand)PIP (middle joint on the finger/joint closest to the thumbnail)DIP (joint closest to the fingernail)DigitsI (thumb)II (index finger)III (middle finger)IV (ring finger)V (pinky)JointsMP (joint that connects the finger/thumb to the hand)PIP (middle joint on the finger/joint closest to the thumbnail)DIP (joint closest to the fingernail)Digits *I (thumb)Joints *MP (joint that connects the thumb to the hand)PIP (joint closest to the thumbnail)Closure Type *Locked-OnEasily RemoveableInclude Transition Kit from Locked-On to Easily Removable (+$3.00)Positioning / Custom Design InstructionsProvider Signature *Your browser does not support e-Signature field.Draw your signature in the boxOrthosis CustomizationColor *BlackSilverWhiteYellowOrangeRedPinkGreenLight BlueDark BluePurpleColors in swatches are approximate. Please see image of casts above for more accurate colors.Add-OnsCotton Undersleeve (+$3.00)Order NotesAgree to Terms *I have read and agree to the terms and conditions of the ActivArmor cast & splint order waiver.Shipping InformationShipping Name *Shipping Email *Shipping Street Address *Apt, Ste, etc...Shipping City *Shipping State *Choose StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingShipping ZIP *0 / 5Billing InformationBilling Info is same as Shipping Info? *YesNoBilling Name *Billing Email *Billing ZIP *0 / 5Closure Calculations (Hidden)Addons Calculations (Hidden)Has Influencer Coupon (Hidden)ApprovedOrthosis Cost$Add-On Cost$Shipping Cost$Orthosis Discount$Shipping Discount$Influencer Discount$Final Cost$Credit / Debit Card *Submit Order
