Patient Name (if different from above):
Please note: For 3/4 length, lifts and other additional special requests for your orthotics along with your personal foot history and symptoms - this information should be added on the questionnaire paperwork included in your kit.
Select Custom Orthotics Type:
( X )
2 Pairs Everyday
2 Pairs Sports
1 Pair Sports & 1 Pair Everyday
loading smart payment buttons...
The payment is ready! It will be completed once you submit the form.
Should be Empty: