Nmotion Orthotic Lab Order Form
163 Cuttawa Lane, Andersonville, TN 37705 USA (865) 765-5650
Account Name
Practitioner Name
*
Ship To DeLoor Podiatry:
*
SELECT
115 East 61st St. BSMT NY, NY 10065
39 West 32nd St. #1503 NY, NY 10001
235 East 22nd St. DR 2, NY, NY 10010
140 N Route17, Paramus , NJ 07652
420 74th St. Brooklyn, NY 11209
8622 Bay Parkway 2B, Brooklyn, NY 11214
65 Broadway Suite 1103 NY, NY 10006
OTHER-Enter address in Special Instructions Field
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Account Email (opt)
Contact me by
Phone
Email
Patient Name
*
Gender
*
Male
Female
Approx. Age
Approx. Weight
Optional
Principal Use
Please Select
Work
Exercise
Casual
Select
Shoe Size
Please Select
Select
3
4
5
5.5
6
6.5
7
7.5
8
8.5
9
9.5
10
10.5
11
11.5
12
12.5
13
14
15
16
17
18
Optional
Shoe Type
*
Please Select
Select
Athletic W/Insole
Extra Depth
Work Boot
Dress W/Permanent Liner
Dress W/Insole
Other(see notes)
Orthotic Details
Orthotic Shell Type
*
Please Select
EVA SOFT
EVA MEDIUM
EVA FIRM
3D Print
Poly-Propylene
Graphite
Select
Lab Discretion
Shell Width/Style
Please Select
Narrow (Inside 1 and 5 mets)
Medium/Standard (Bisect 1/Outside 5)
Wide (Outside 1 and 5)
Cobra
UCBL (Extra Deep)
Other
Heel Depth
Please Select
Standard 12-15 mm
Low 8-10 mm
Deep 16-18 mm
UCBL 20-24 mm
Shell Rigidity
Please Select
Accommodate only (SOFT)
Flexible
Semi-Rigid
Rigid 4mm Plastics
Select
Arch Height Conformity
Lab Discretion
Full Arch
Reduce Arch 2mm
Reduce Arch 3mm
Reduce Arch 4mm
Support Arch Under Shell
Lab Discretion
Soft Arch Fill
Firm Arch Fill
Met Pads
Please Select
None (Standard)
Bi-Lateral
Right Only
Left Only
Met Details
Please Select
Medium-Soft 3mm
Medium-Firm 3mm
Low- Soft 1.5 mm
Low-Firm 1.5 mm
High-Soft 5 mm
High-Firm 5mm
None Selected
Other
Heel Spur Pad "U"
Please Select
None (Standard)
Left Only
Right Only
Bi-Lateral
Full Heel Cushion
Please Select
None (Standard)
Left Only
Right Only
Bi=Lateral
Morton's Extension
Please Select
None (Standard)
Left Only
Right Only
Bi-Lateral
Reverse Morton's
Please Select
None (Standard)
Left Only
Right Only
Bi-Lateral
1st Met Cutout
Please Select
Left Only
Right Only
Bi-Lateral
None (Standard)
1st RAY Cutout
Please Select
None (Standard)
Left Only
Right Only
Bi-Lateral
Heel Post Method
Please Select
Lab Discretion
Intrinsic
Extrinsic
Heel Post Bias
Medial/Varus
Lateral/Valgus
Rt Heel Post Amt.
Left Heel Post Amt.
Forefoot Posting
Please Select
Lab Discretion
Intrinsic
Extrinsic
FFoot Post Bias
Medial/Varus
Lateral/Valgus
Right FF Post Amt.
Left FF Post Amt.
Cover Length
Please Select
Same as Shell 3/4
To Sulcus 7/8 Behind toes
Full Length
Full Length is Default
Cover Material
Please Select
EVA 1/16"
EVA 1/8"
EVA 3/16"
Spenco 1/16"
Spenco 1/8"
Vinyl
Plastazote 1/8"
Plastazote 3/16"
Lab Discretion
Extra Cushion
Please Select
PPT 1/16"
PPT 1/16" Under Forefoot
PPT 1/16" Length of Shell
PPT 1/16" To Sulcus
PPT 1/8"
PPT 1/8" Under Forefoot
PPT 1/8" Length of Shell
PPT 1/8" To Sulcus
EVA 1/16" Full Length
EVA 1/16" Under Forefoot
EVA 1/16" Length of Shell
EVA 1/16" To Sulcus
EVA 1/8"
EVA 1/8" Under Forefoot
EVA 1/8" Length of Shell
EVA 1/8" To Sulcus
None (Standard)
Heel Lift
Additional Instructions And/Or Request for Supplies
Date Submitted
-
Month
-
Day
Year
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