RUSH ORDER:
2 Day - $20
3 Day - $15
Patients Name
Date
-
Month
-
Day
Year
Date Picker Icon
Doctors Name
Telephone
-
Area Code
Phone Number
Email Address
Address
City
State
Zip Code
Age
Weight
Sex
Please Select
Male
Female
Shoe Size
Shoe Type
Chief Complaint:
Pouring Insructions:
Perpendicular
As Is
Inverted
Right:
Degree
Left:
Degree
Forefoot Posting:
Intrinsic
Extrinsic
RIGHT:
Varus
Degree
Valgus
Degree
LEFT:
Varus
Degree
Valgus
Degree
SPECIFICATIONS:
Heel Cup Depth:
Normal
Deep
Shallow
Orthotic Width:
Normal
Wide
Narrow
Arch Fill:
Normal
Heavy
Light
Polypropylene:
Please Select
3/32” (2.3mm)
1/8” (3.2mm)
5/32” (4.0mm)
3/16” (4.7mm)
1/4” (6.4mm)
Carboplast II:
Please Select
Flexible (1.5mm)
Semi-Rigid (2.0mm)
Rigid ( 2.5mm)
NW DBX6:
Please Select
Semi-Rigid (1.5mm)
Rigid (1.5mm)
TL 2100:
Please Select
Flexible (1.8mm)
Semi-Rigid (2.2mm)
Rigid (2.8mm)
Ultra (2.8mm)
Specialty Sport:
Please Select
Aerobic 1/16"
Aerobic 1/8"
Super Sport
Ski Orthotic
Specialty Dress:
Please Select
Cobra Style
Carbo Dress
Poly Dress Black
Poly Dress Brown
Accommodative Orthotic:
Functional
Non-Functional
Polypropylene Shell:
Please Select
None
1/16” (1.6mm)
1/8” (3.2mm)
Arch Fill:
Please Select
Soft
Medium
Firm
Bottom Cover:
Please Select
Multi-Cork
HR EVA
None
Specialty Accommodative:
Soft Step
Diabetic
Cork & Leather
Childrens’ Orthotic:
Rearfoot Controller
Galt Plate
Reversed Galt Plate
Special Work #1
Please Select
PF Groove
Metatarsal Pads
1st Ray Cut Out
Kirby Skive
Horse Shoe Pads
Medial Flange
EVA Arch Fill
Mortons Extension
Rev. Mortons Extension
Poron Arch Fill
Silipos Relief Pads
Metatarsal Bars
mm #1
Foot #1
Left
Right
Special Work #2
Please Select
PF Groove
Metatarsal Pads
1st Ray Cut Out
Kirby Skive
Horse Shoe Pads
Medial Flange
EVA Arch Fill
Mortons Extension
Rev. Mortons Extension
Poron Arch Fill
Silipos Relief Pads
Metatarsal Bars
mm #2
Foot #2
Left
Right
Special Work #3
Please Select
PF Groove
Metatarsal Pads
1st Ray Cut Out
Kirby Skive
Horse Shoe Pads
Medial Flange
EVA Arch Fill
Mortons Extension
Rev. Mortons Extension
Poron Arch Fill
Silipos Relief Pads
Metatarsal Bars
mm #3
Foot #3
Left
Right
Rear Foot Posting:
None
4/4
Polypropylene
Birkocork
Crepe 60 Duro
Crepe 70 Duro
Petite Post
Heel Lift
Heel Hole
Comments
Cushion Top Cover:
Poron 1/16"
Poron 1/8"
HR Eva 1/16"
HR Eva 1/8"
Met Length
Full Length
Sulcus Length
Extension Only:
Poron 1/16"
Poron 1/8"
HR Eva 1/16"
HR Eva 1/8"
Multi-Cork 1/16"
Multi-Cork 1/8"
Full Length
Sulcus Length
Top Covers:
None
Leather
Black
Vinyl
Ultrasuede
Tan
Top Covers:
Spenco
EVA/Pu
Ucolite
Static-X
Size
1/16"
1/8"
Length
Met Length
Sulcus Length
Full Length
Bottom Covers:
Vinyl
Ultraseude
EVA/Puff
Multi-Cork
Positive Castings:
Stored
Returned
Special Instructions:
Enter the message as it's shown
*
Submit
Should be Empty: