Clinician Email
example@example.com
WIDE NUMBER
This number will be added by Wide Lab and printed onto the FFO
Patient Name
First Name
Last Name
Clinician Name
First Name
Last Name
Clinic Name
Mobile Number
Shipping Address
Number
Street Address
City
State / Province
Post Code
Orthotic Prescription Form
Shoe Size UK
*
Please Select
3
3.5
4
4.5
5
5.5
6
6.5
7
7.5
8
8.5
9
9.5
10
10.5
11
11.5
12
12.5
13
13.5
14
14.5
Fasthotics® Shell Size
*
Please Select
A (Fits average size 4 UK)
A+ (Fits average size 5 UK)
B (Fits average size 6 UK)
C (Fits average size 7 UK)
D (Fits average size 8 UK)
E (Fits average size 9 UK)
F (Fits average size 10 UK)
F+ (Fits average size 11 UK)
G (Fits average size 12 UK)
H (Fits average size 13 UK)
Shell Material
Fasthotics® 3mm Black Polypropylene
Top Cover
*
Please Select
3mm Comfort Black Marble EVA
1mm Comfort Black Marble EVA
1mm Comfort Blue Marble EVA
1mm Comfort Pink Marble EVA
2.5mm Perforated Antibacterial Breathable EVA
0.8mm Breathable Leather
1.5mm Wipeable Leather
1.6mm Spenco Sport
3mm Spenco Sport
3mm Leather x XRD Impact Sport
Total Length
*
Full
3/4
Sulcus
Express or Detailed Prescription
Type Prescription
Clickable Prescription
Enter Prescription
Extra Mid Layer
Tick
Material
Length
MM
Midlayer
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
Full Length
3/4 Shell Only
Forepart Extension
1.6mm
3.2mm
Left Heel Raise
Please Select
0mm
1mm
2mm
3mm
4mm
5mm
6mm
7mm
8mm
9mm
10mm
Right Heel Raise
Please Select
0mm
1mm
2mm
3mm
4mm
5mm
6mm
7mm
8mm
9mm
10mm
Left Rearfoot / Forefoot Posting
Tick
MM
Intrinsic Rearfoot Varus (Medial) Post
1mm
2mm
3mm
4mm
5mm
6mm
Intrinsic Rearfoot Valgus (Lateral) Post
1mm
2mm
3mm
4mm
5mm
6mm
Intrinsic Forefoot Valgus (Lateral) Post
1mm
2mm
3mm
4mm
5mm
6mm
Intrinsic Forefoot Varus (Medial) Post
1mm
2mm
3mm
4mm
5mm
6mm
Extrinsic EVA Rearfoot Varus (Medial) Post
1mm
2mm
3mm
4mm
5mm
6mm
Extrinsic EVA Rearfoot Valgus (Lateral) Post
1mm
2mm
3mm
4mm
5mm
6mm
Extrinsic EVA Forefoot Varus (Medial) Post
1mm
2mm
3mm
4mm
5mm
6mm
Extrinsic EVA Rearfoot Valgus (Lateral) Post
1mm
2mm
3mm
4mm
5mm
6mm
Semi Rigid Mortons Extension
1mm
2mm
3mm
4mm
5mm
6mm
Semi Rigid Reverse Mortons Extension
1mm
2mm
3mm
4mm
5mm
6mm
Right Rearfoot / Forefoot Posting
Tick
MM
Intrinsic Rearfoot Varus (Medial) Post
1mm
2mm
3mm
4mm
5mm
6mm
Intrinsic Rearfoot Valgus (Lateral) Post
1mm
2mm
3mm
4mm
5mm
6mm
Intrinsic Forefoot Valgus (Lateral) Post
1mm
2mm
3mm
4mm
5mm
6mm
Intrinsic Forefoot Varus (Medial) Post
1mm
2mm
3mm
4mm
5mm
6mm
Extrinsic EVA Rearfoot Varus (Medial) Post
1mm
2mm
3mm
4mm
5mm
6mm
Extrinsic EVA Rearfoot Valgus (Lateral) Post
1mm
2mm
3mm
4mm
5mm
6mm
Extrinsic EVA Forefoot Varus (Medial) Post
1mm
2mm
3mm
4mm
5mm
6mm
Extrinsic EVA Rearfoot Valgus (Lateral) Post
1mm
2mm
3mm
4mm
5mm
6mm
Semi Rigid Mortons Extension
1mm
2mm
3mm
4mm
5mm
6mm
Semi Rigid Reverse Mortons Extension
1mm
2mm
3mm
4mm
5mm
6mm
Left Shell Cut Out
Tick
Fill
1st MPJ Cut Out
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
1st Ray Cut Out
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
5th MPJ Cut Out
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
Heel Cut Out
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
Right Shell Cut Out
Tick
Fill
1st MPJ Cut Out
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
1st Ray Cut Out
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
5th MPJ Cut Out
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
Heel Cut Out
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
Left Accommodations
Tick
Thickness
Material
Met Bar
Lab Standard
1mm
2mm
3mm
4mm
5mm
6mm
7mm
8mm
9mm
10mm
12mm
13mm
14mm
15mm
16mm
17mm
18mm
19mm
20mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
Met Dome
Lab Standard
1mm
2mm
3mm
4mm
5mm
6mm
7mm
8mm
9mm
10mm
12mm
13mm
14mm
15mm
16mm
17mm
18mm
19mm
20mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
Reverse Morton's Extension
Lab Standard
1mm
2mm
3mm
4mm
5mm
6mm
7mm
8mm
9mm
10mm
12mm
13mm
14mm
15mm
16mm
17mm
18mm
19mm
20mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
Morton's Extension
Lab Standard
1mm
2mm
3mm
4mm
5mm
6mm
7mm
8mm
9mm
10mm
12mm
13mm
14mm
15mm
16mm
17mm
18mm
19mm
20mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
Kinetic Wedge
Lab Standard
1mm
2mm
3mm
4mm
5mm
6mm
7mm
8mm
9mm
10mm
12mm
13mm
14mm
15mm
16mm
17mm
18mm
19mm
20mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
Heel Cushioning
Lab Standard
1mm
2mm
3mm
4mm
5mm
6mm
7mm
8mm
9mm
10mm
12mm
13mm
14mm
15mm
16mm
17mm
18mm
19mm
20mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
Arch Pad (Valgus Pad)
Lab Standard
1mm
2mm
3mm
4mm
5mm
6mm
7mm
8mm
9mm
10mm
12mm
13mm
14mm
15mm
16mm
17mm
18mm
19mm
20mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
1-2 Neuroma Pad
Lab Standard
1mm
2mm
3mm
4mm
5mm
6mm
7mm
8mm
9mm
10mm
12mm
13mm
14mm
15mm
16mm
17mm
18mm
19mm
20mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
2-3 Neuroma Pad
Lab Standard
1mm
2mm
3mm
4mm
5mm
6mm
7mm
8mm
9mm
10mm
12mm
13mm
14mm
15mm
16mm
17mm
18mm
19mm
20mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
4-5 Neuroma Pad
Lab Standard
1mm
2mm
3mm
4mm
5mm
6mm
7mm
8mm
9mm
10mm
12mm
13mm
14mm
15mm
16mm
17mm
18mm
19mm
20mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
Cuboid Pad
Lab Standard
1mm
2mm
3mm
4mm
5mm
6mm
7mm
8mm
9mm
10mm
12mm
13mm
14mm
15mm
16mm
17mm
18mm
19mm
20mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
Right Accommodations
Tick
Thickness
Material
Met Bar
Lab Standard
1mm
2mm
3mm
4mm
5mm
6mm
7mm
8mm
9mm
10mm
12mm
13mm
14mm
15mm
16mm
17mm
18mm
19mm
20mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
Met Dome
Lab Standard
1mm
2mm
3mm
4mm
5mm
6mm
7mm
8mm
9mm
10mm
12mm
13mm
14mm
15mm
16mm
17mm
18mm
19mm
20mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
Reverse Morton's Extension
Lab Standard
1mm
2mm
3mm
4mm
5mm
6mm
7mm
8mm
9mm
10mm
12mm
13mm
14mm
15mm
16mm
17mm
18mm
19mm
20mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
Morton's Extension
Lab Standard
1mm
2mm
3mm
4mm
5mm
6mm
7mm
8mm
9mm
10mm
12mm
13mm
14mm
15mm
16mm
17mm
18mm
19mm
20mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
Kinetic Wedge
Lab Standard
1mm
2mm
3mm
4mm
5mm
6mm
7mm
8mm
9mm
10mm
12mm
13mm
14mm
15mm
16mm
17mm
18mm
19mm
20mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
Heel Cushioning
Lab Standard
1mm
2mm
3mm
4mm
5mm
6mm
7mm
8mm
9mm
10mm
12mm
13mm
14mm
15mm
16mm
17mm
18mm
19mm
20mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
Arch Pad (Valgus Pad)
Lab Standard
1mm
2mm
3mm
4mm
5mm
6mm
7mm
8mm
9mm
10mm
12mm
13mm
14mm
15mm
16mm
17mm
18mm
19mm
20mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
1-2 Neuroma Pad
Lab Standard
1mm
2mm
3mm
4mm
5mm
6mm
7mm
8mm
9mm
10mm
12mm
13mm
14mm
15mm
16mm
17mm
18mm
19mm
20mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
2-3 Neuroma Pad
Lab Standard
1mm
2mm
3mm
4mm
5mm
6mm
7mm
8mm
9mm
10mm
12mm
13mm
14mm
15mm
16mm
17mm
18mm
19mm
20mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
4-5 Neuroma Pad
Lab Standard
1mm
2mm
3mm
4mm
5mm
6mm
7mm
8mm
9mm
10mm
12mm
13mm
14mm
15mm
16mm
17mm
18mm
19mm
20mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
Cuboid Pad
Lab Standard
1mm
2mm
3mm
4mm
5mm
6mm
7mm
8mm
9mm
10mm
12mm
13mm
14mm
15mm
16mm
17mm
18mm
19mm
20mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
Left Sinks & Fills
Tick
Thickness
Fill
1st
1.6mm
3mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
2nd
1.6mm
3mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
3rd
1.6mm
3mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
4th
1.6mm
3mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
5th
1.6mm
3mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
Right Sinks & Fills
Tick
Thickness
Fill
1st
1.6mm
3mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
2nd
1.6mm
3mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
3rd
1.6mm
3mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
4th
1.6mm
3mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
5th
1.6mm
3mm
Grey Poron 4000
Yellow Poron XRD
Blue Medical 4708 Poron
Pink 2055 Poron
A30 EVA
Other Details
Payment
*
Pay Online Save 10% £43.20 Per Pair
Pay On Account £48.00 Per Pair
Checkout
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Semi Custom Orthotic
Made to prescription above
£
43.20
Quantity
1
2
3
4
5
24 Hour Postage
If you are ordering multiple orthoses then please only apply postage to one order and we will send all together.
£
4.00
Quantity
1
Item subtotal:
£
0.00
Pack of Fasthotics shells A-F
Great for keeping in clinic and choosing shell size for your patients
£
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
PO Number / Reference
This will be noted on invoice
PLACE ORDER
Should be Empty: