Orthotic Order Now

Orthotic Order Form

GENERAL

Provider Name:

Clinic/Hospital Name:

Shipping Address:

City:

State:

Zip Code:

Phone Number

PO#
(optional)

Email

Please Check the box if billing Address is same as shipping Address.

Billing Address:

City:

State:

Zip Code:

PATIENT

Patient Name:

Patient Age:

Patient Weight:

Gender: MaleFemale

Shoe Size:

Shoes:MensWomens

Shoe Width:RegularNarrowWide

SHIPPING

Shipping:

SHAPE CAPTURE OPTIONS

Shape Capture Options:

Upload Scan:

POSTING

Rearfoot Posting:

IntrinsicExtrinsic

Left:

Varus:

Valgus:

Right

Varus:

Valgus:

Heel Lift

Left:

Right:

Heel Cup:

Forefoot Posting

IntrinsicExtrinsic

Left

Varus:

Valgus:

Right

Varus:

Valgus:

Heel Lift

Left:

Right:

Medial Arch Fill:

MATERIALS

Footplate-Flex:

Forefoot Materials:

EVA:

Multicork:

Heel Materials:

EVA:

Multicork:

Top Cover Materials

Add Poron Cushion

Bottom Cover Materials

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: