Diabetic Foot Orthotic Order Form
If you need any assistance, email success@protosthetics.com or call us at (701)-478-2001
Practitioner Name
*
First Name
Last Name
Practitioner Email
*
example@example.com
PO#
*
Facility Name
*
Need By
-
Month
-
Day
Year
Date
Shipping Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DELIVERY METHOD
*
Please Select
Ground
2-day (additional charges)
Overnight (additional charges)
Local Pickup
Patient Information
Have a Tech Call Me
Yes
Shoe size
*
Diagnosis/Special Instructions
Sides
*
Pair
Right
Left
Fabrication Instructions
Left Quantity
Please Select
—
1 Pair
2 Pair
3 Pair
Left Type
Please Select
—
Standard
L5000
Right Quantity
Please Select
—
1 Pair
2 Pair
3 Pair
Right Type
Please Select
—
Standard
L5000
Base Layer Density
*
Soft 35A EVA
55A Multicork
Top Cover
*
Please Select
—
1/8" P-Cell
1/16" Poron, 1/16" P-Cell
1/16" Poron, 1/8" P-Cell
Metatarsal Pads
Please Select
—
Right
Left
Both
Metatarsal Bars
Please Select
Right
Left
Both
Medial Flange
Please Select
—
Right
Left
Both
Lateral Flange
Please Select
—
Right
Left
Both
Additional Information
Note: Protosthetics can only make products as well as you describe your needs — please be thorough!
Preview PDF
Submit
Should be Empty: