The Orthotic Group Form

TOG PRESCRIPTION ORDER FORM
Patient Name *
Date of Birth (M/D/Y) *

Month Day Year
Date
Sex *

M F
Weight *
Height *
Shoe Size *
Shoe Type *
Main Activities *
EXAMINATION FINDINGS
CHIEF COMPLAINTS / SPECIAL INSTRUCTIONS
Straight

Toe out
Type a question

Type option 1 Type option 2 Type option 3 Type option 4
OPTIONAL FINDINGS
General Foot Motion Left Right Restricted Normal
Forefoot varus Left Right

Moderate Severe Forefoot valgus Left Right
Moderate Severe

Insoles Enclosed Rush ($25 additional charge) Total # of pairs: Repair/Adjustment ($25 charge may apply) ORDER INFORMATION Insole Tracing Enclosed Shoes Enclosed Ankle Dorsi-Flexion LeftRight Adequate Limited Mild Moderate Severe
ORTHOTICS
KidsFlex* *Children less than 60lbs or younger than 6 years old. CushionFlex
TOG OFFICE NOTES ONLY
ADDITIONS/MODIFICATIONS
Full Heel Cushion

Neuroma Pad Metatarsal Pad Forefoot Pad Sub-Metatarsal
Interspace
Interspace
Heel Spur Pad

Rearfoot Extrinsic Post
(greater than 280lbs)

Morton's Extension Reinforced Arch
mm Rmm

Medial Skive
mm Rmm

Lateral Skive
TPlease send photocopy or tracing of insole
Extension

Reverse Morton's Extrinsic Forefoot Heel Lift
mm R mm
R L

With foam disk
SPECIALTY ORTHOTICS
Post (3/4 length)
mm
mm
Deep Heel Cups

Heel Spur Pad full length Medial Flange Modifications Available: Heel Lift
R

Deep Heel Cups 1st Metatarsal Extrinsic Forefoot Vinyl Sandwich
UCBL
(Bilateral)
Special Features

3/4 length only 1mm black naugahyde topcover High medial and lateral flanges and deep heel cups
Cut Out
-0-95
SPECIAL TOPCOVER REQUESTS
3/4 length only 1mm black naugahyde topcover
Extra Foam Padding under Topcover

2mm Induce toe out 3.5mm Induce toe in 3mm /16
Full weight bearing cast only
Full weight bearing cast only

full length sulcus Other Topcover (Please Specifiy) Suede Leather Topcover on Orthotic ($10 additional charge)
FOOTWEAR
Footwear
Colour
Footwear
Colour
Size

Men's Women's
Size
Width

Women's Footwear Shell Only (no orthotic) Footwear Shell Only (no orthotic) Standard Orthotic Standard Orthotic Other Orthotic (please specify) 2mm 3mm 3.5mm *1mm applies to all Sandals Other Orthotic (please specify)
Width
Women's

Men's
Size
Width
Orthotic Thickness

2mm 3.5mm *1mm applies to all Sandals 3mm
Orthotic Thickness *
Returning
Exchange For

Yes Orthotic Included
Exchange For
Yes

No
Name of Insurance Company
Practitioner's Signature

Clear
Date

Month Day Year
Date
Send white copy to TOG. Keep yellow copy for practitioner records.
Muscle & Joint Clinic
clinic@muscleandjoint.ca www.muscleandjoint.ca
Date

Month Day Year
Date
Dr F Malik/ Dr R Cheng/S.Gautam
Health Practitioner
Discipline
Patient Name
DOB
Custom made orthotics have been prescribed for the above-mentioned patient insured by your company. These custom orthotics have been prescribed in response to the following symptoms, gait analysis and biomechanical evaluation.
The medical diagnosis, symptoms and exam findings that require the use of custom orthotic foot devices are as follows

Knee Osteoarthritis Anterior Tibialis Shin Splints Bunions Abnormal Patellar Tracking Abnormal Gait Patellar Femoral Syndrome Drop Foot Metatarsalgia Plantar Fasciitis Lower Back Pain Sacroiliac Joint Inflammation ITB Syndrome Achilles Tendonitis Heel Spurs Peroneus Tendonitis Hammer Toes Hallux Limitus/Rigidus Peripheral Neuropathy Other:
Gait analysis and Biomechanical Evaluation: Our examination reveals the following imbalances to be contributing to the above problems

Subtalar Overpronation R L Supination Forefoot Whole Foot Functional Genu Valgus R L Functional Genu Varus L R Other:
Diagnosis
Prognosis: The custom orthotics are a medical necessity and must be worn on a day-to-day basis, for an indefinite period of time. Wearing custom orthotics will alleviate the symptoms caused in the foot, hip, and low back. The orthotics, the feet and gait should be monitored to watch for change in prescription or breakdown of the device. Casting Technique: Non-weight bearing 3D volumetric cast in subtalar neutral. This data is scanned by technicians. Copolymer plastic is formed over the positive to create a custom orthotic for the patient's specific correction and symptomatic needs. Manufacturing Laboratory: The Orthotic Group Inc. Markham ON. Fee: See accompanying invoice. No part of these fees are covered by OHIP.
160 Markland Street The 25OrthoticCANADAMarkham, Ontario L6C 0C6 Groupwww.theorthoticgroup.com 1 800 551 3008
ACCOUNT #
Canadian Muscle & Joint Pain Clinic Dr. Malik 5980 Churchill Meadows Blvd Unit #4 Mississauga , ON L5M 7M5 Canada 905-593-1605

Laboratory Information The Orthotic Group Manufacturing podiatry type custom orthotics since 1985 160 Markland Street, Markham, ON, L6C 0C6, Canada

Alan M. Lustig, D.P.M (Chief Medical Director of TOG)

Raw Materials/Manufacturing Vacuum formed copolymer plastic with complete intrinsic memory (thickness and width prescription specific) Prescription specific additions, modifications and top coverings

Casting Technique 3D Volumetric Cast (foam)
PATIENT INFORMATION
Should be Empty: