Foot Orthotic Order Now

Functional FO Order Form

ORDER INFORMATION

Order Date:

Lead Time:

Date Needed (additional charges may apply):

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:

Weight (lbs):

Sex:

DOB:

Shoe Size:

Shell Length:

Midlayer Length:

Top Cover Length:

Shoe Type:

CasualDressAthletic

Diagnosis/Special Instructions:
Have a Tech Call Me

 

QUANTITY

Quantity:

SHAPE CAPTURE OPTIONS

Shape Capture Options:

Please email scans to scans@protosthetics.com

POSTING

Intrinsic or Extrinsic:

ExtrinsicIntrinsic

Correction Findings:

Correct to Measurements ListedPractitioner Findings Listed

Rearfoot Posting:

Left:

Varus:

Valgus:

Right

Varus:

Valgus:

Heel Lift

Left:

Right:

Heel Cup:

Forefoot Posting

Left:

Varus:

Valgus:

Right

Varus:

Valgus:

Forefoot Lift

Left:

Right:

MATERIALS

Footplate-Flex:

Forefoot Posting Materials:

EVA:

Multicork:

Heel Posting Materials:

EVA:

Multicork:

Top Cover Materials:

EVA:

Duraform EVA:

Leather:

NeoSponge:

Midlayer Material:

Forefoot Bottom Cover Material:

Heel Bottom Cover Material:

Shearban Relief:

Medial Arch Fill:

MODIFICATIONS

LR 1st Ray Cut-Out

LR 5th Ray Cut-Out

LR Deep Heel Seat

LR Heel Punch-Out

LR Lateral Flange

LR Morton's Extension

LR Promote In Toe

LR Promote Out Toe

LR Heel Spur Cut-Out

LR Metatarsal Pad

ADDITIONAL COMMENTS

Additional Comments: