Diabetic FO Order Now

Diabetic 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:

    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