Foot Orthotic Order Now

Foot Orthotic Order Form

GENERAL

Clinic/Hospital Name:

Provider Name:

Shipping Address:

City:

State:

Zip Code:

Phone Number:

Billing Point of Contact:

Billing Contact Email:

PO#:(optional)

Email:

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

Billing Address:

City:

State:

Zip Code:

PATIENT

First Name:

Last Name:

Birthday:

Weight (lbs):

Shoe Size:

Gender:

MaleFemale

Orthotic Length:

FullSulcusShell(-$5)

Shoe Type:

CasualDressAthletic

LEAD TIME

Lead Time:

QUANTITY

Quantity:

SHAPE CAPTURE OPTIONS

Shape Capture Options:

Please email scans to scans@protosthetics.com

POSTING

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

LRHeel Spur Cut-Out

ADDITIONAL COMMENTS

Additional Comments: