The Orthotic Group Form

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

MonthDayYear
Date
MF
Weight*
Height*
Shoe Size*
Shoe Type*
Main Activities*
EXAMINATION FINDINGS
CHIEF COMPLAINTS / SPECIAL INSTRUCTIONS
Toe out
Type option 1Type option 2Type option 3Type option 4
OPTIONAL FINDINGS
General Foot Motion Left Right Restricted Normal
Moderate SevereForefoot valgus Left Right
Insoles EnclosedRush ($25 additional charge) Total # of pairs: Repair/Adjustment ($25 charge may apply)ORDER INFORMATIONInsole Tracing Enclosed Shoes EnclosedAnkle Dorsi-Flexion LeftRight Adequate LimitedMild Moderate Severe
ORTHOTICS
KidsFlex* *Children less than 60lbs or younger than 6 years old. CushionFlex
TOG OFFICE NOTES ONLY
ADDITIONS/MODIFICATIONS
Neuroma PadMetatarsal PadForefoot PadSub-Metatarsal
Interspace
Interspace
Rearfoot Extrinsic Post
Morton's ExtensionReinforced Arch
Medial Skive
Lateral Skive
TPlease send photocopy or tracing of insole
Reverse Morton'sExtrinsic ForefootHeel Lift
mm R mm
With foam disk
SPECIALTY ORTHOTICS
Post (3/4 length)
mm
mm
Heel Spur Padfull lengthMedial FlangeModifications Available:Heel Lift
Deep Heel Cups1st MetatarsalExtrinsic ForefootVinyl Sandwich
UCBL
(Bilateral)
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
2mmInduce toe out3.5mmInduce toe in3mm/16
Full weight bearing cast only
full lengthsulcusOther Topcover (Please Specifiy)Suede Leather Topcover on Orthotic ($10 additional charge)
FOOTWEAR
Footwear
Colour
Footwear
Colour
Men'sWomen's
Size
Women'sFootwear Shell Only (no orthotic)Footwear Shell Only (no orthotic)Standard OrthoticStandard OrthoticOther Orthotic (please specify)2mm3mm3.5mm *1mm applies to all SandalsOther Orthotic (please specify)
Width
Men's
Size
Width
2mm3.5mm *1mm applies to all Sandals3mm
Orthotic Thickness*
Returning
YesOrthotic Included
Exchange For
No
Name of Insurance Company
Practitioner's Signature
Date

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

MonthDayYear
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.
Knee OsteoarthritisAnterior Tibialis Shin SplintsBunionsAbnormal Patellar TrackingAbnormal GaitPatellar Femoral SyndromeDrop FootMetatarsalgiaPlantar FasciitisLower Back PainSacroiliac Joint InflammationITB SyndromeAchilles TendonitisHeel Spurs Peroneus TendonitisHammer ToesHallux Limitus/RigidusPeripheral NeuropathyOther:
Subtalar OverpronationRLSupinationForefootWhole FootFunctional Genu ValgusRLFunctional Genu VarusLROther:
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:

TOG PRESCRIPTION ORDER FORM

EXAMINATION FINDINGS

CHIEF COMPLAINTS / SPECIAL INSTRUCTIONS

OPTIONAL FINDINGS

ORTHOTICS

ADDITIONS/MODIFICATIONS

SPECIALTY ORTHOTICS

UCBL

SPECIAL TOPCOVER REQUESTS

FOOTWEAR

Muscle & Joint Clinic

PATIENT INFORMATION