FASTHOTICS.COM

Clinician Email

example@example.com

WIDE NUMBER

This number will be added by Wide Lab and printed onto the FFO

Patient Name

First NameLast Name

Clinician Name

First NameLast Name

Clinic Name

Mobile Number

Shipping Address

Number

Street Address

City

Post Code

Shoe Size UK*

Fasthotics® Shell Size*

Shell Material

Fasthotics® 3mm Black Polypropylene

Top Cover*

Total Length*

Full3/4Sulcus

Express or Detailed Prescription

Type PrescriptionClickable Prescription

Footscan / Pressure Plate PDF Upload, this will allow us to choose the best shell size for your patient and also have the correct information to apply sinks, cut outs and met pad placements.

Not uploading will waive your rights to an adaption and a new pair will need to be ordered if making changes.

Enter Prescription

Extra Mid Layer

Rows	Tick	Material	Length	MM
Midlayer

Left Heel Raise

Please choose the stability post option at bottom of form

Right Heel Raise

Please choose the stability post option at bottom of form

Left Rearfoot / Forefoot Posting

Rows	Tick	Degree
Intrinsic Rearfoot Varus (Medial) Post
Intrinsic Rearfoot Valgus (Lateral) Post
Intrinsic Forefoot Valgus (Lateral) Post
Intrinsic Forefoot Varus (Medial) Post

Right Rearfoot / Forefoot Posting

Rows	Tick	Degree
Intrinsic Rearfoot Varus (Medial) Post
Intrinsic Rearfoot Valgus (Lateral) Post
Intrinsic Forefoot Valgus (Lateral) Post
Intrinsic Forefoot Varus (Medial) Post

Left Shell Adjustments

Rows	Tick	Fill
1st MPJ Cut Out
1st Ray Cut Out
5th MPJ Cut Out
Semi Rigid Mortons Extension
Semi Rigid Reverse Mortons Extension
MD EVA Medial Flange

Right Shell Adjustments

Rows	Tick	Fill
1st MPJ Cut Out
1st Ray Cut Out
5th MPJ Cut Out
Semi Rigid Mortons Extension
Semi Rigid Reverse Mortons Extension
MD EVA Medial Flange

Left Accommodations

Rows	Tick	Thickness	Material
Met Bar
Met Pad
Met Dome
Reverse Morton's Extension
Morton's Extension
Kinetic Wedge
Heel Cushioning
Arch Pad (Valgus Pad)
1-2 Neuroma Pad
2-3 Neuroma Pad
4-5 Neuroma Pad
Cuboid Pad
15mm High Medial Flange

Right Accommodations

Rows	Tick	Thickness	Material
Met Bar
Met Pad
Met Dome
Reverse Morton's Extension
Morton's Extension
Kinetic Wedge
Heel Cushioning
Arch Pad (Valgus Pad)
1-2 Neuroma Pad
2-3 Neuroma Pad
4-5 Neuroma Pad
Cuboid Pad
15mm High Medial Flange

Left Sinks & Fills

Rows	Tick	Thickness	Fill
1st
2nd
3rd
4th
5th

Right Sinks & Fills

Rows	Tick	Thickness	Fill
1st
2nd
3rd
4th
5th

Other Details

Payment*

Pay Online Save 10%Pay On Account £48.00 Per PairPay On Account / Stability Heel Posting £60.00

Checkout

Semi Custom Orthotic

Made to prescription above

£43.20 Quantity

Post & Packaging

If you are ordering multiple orthoses then please only apply postage to one order and we will send all together.

£5.00 Quantity
Item subtotal:£0.00

Add Extrinsic Stability Posts

Any intrinsic posting will be applied extrinsically, also please choose this option if you have entered a heel raise.

£12.00 Quantity

Total

£0.00

PO Number / Reference

This will be noted on invoice

Orthotic Prescription Form