Diabetic FO Order Now

Diabetic FO Order Form

ORDER INFORMATION

Order Date:

Lead Time:

Date Needed:

PO#:

 

SHIPPING INFORMATION

Facility:

Practitioner:

Address:

City:

State:

Zip Code:

Phone:

Email:

BILLING INFORMATION

Please check the box if billing address is same as shipping address.

Facility:

Practitioner:

Address:

City:

State:

Zip Code:

Phone:

Email:

SHIPPING INSTRUCTIONS

Ground2-day (additional charges)Overnight (additional charges)Local

PATIENT INFORMATION

Name:

Sex:

DOB:

Shoe Size:

Diagnosis/Special Instructions:
Have a Tech Call Me

 

FABRICATION INSTRUCTIONS

Quantity:

Base Layer Density:

Top Cover:

Metatarsal Pads:

Medial Flange:

Lateral Flange:

Special Instructions:

SCANS

Please email scans to scans@protosthetics.com