Accommodative Foot Orthotics 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#
*
Need By
-
Month
-
Day
Year
Date
Facility Name
*
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
Diagnosis/Special Instructions
Have a Tech Call Me
Yes
Sides
*
Left
Right
Pair
Shoe size
*
Fabrication Instructions
Base Material
*
Please Select
—
Comfort (35A EVA)
Stroller (35A EVA Heel Cup & Medial Arch Support, 20A P-Cell Plantar Surface, 55A EVA Bottom)
Strider (55A EVA Heel Cup & Medial Arch Support, 35A EVA Plantar Surface, 65A EVA Bottom)
Support (55A Multi-cork EVA)
Base Length
*
Please Select
Full
To Sulcus
To Mets
Midlayer Material
*
Please Select
—
Basic Poron
Sport Poron (Additional Charge)
Slow Recovery Poron (Additional Charge)
Midlayer Thickness
*
Please Select
—
1/16"
1/8"
Midlayer Length
*
Please Select
—
Full
To Sulcus
To Mets
Extend from Shell
Top Cover Material
*
Please Select
—
EVA
P-Cell
NeoSponge
DuraFORM (Additional Charge)
NeoSponge w/ X-Static (Additional Charge)
Top Cover Thickness
*
Please Select
—
1/16"
1/8"
Top Cover Length
*
Please Select
—
Full
To Sulcus
To Mets
ADDITIONS
Metatarsal Pads
Left
Right
Metatarsal Bars
Left
Right
Deep Heel Cup
Left
Right
ADDITIONAL INFORMATION
Note: Protosthetics can only make products as well as you describe your needs — please be thorough!
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