Diabetic FO Order Now Diabetic FO Order Form ORDER INFORMATION Order Date: Lead Time: 7-9 Days5 Day (+$20)2 Day (+$50)Local Pickup 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: ---MaleFemale DOB: Shoe Size: Diagnosis/Special Instructions: Have a Tech Call Me FABRICATION INSTRUCTIONS Quantity: ---1 Pair2 Pair3 PairLeft OnlyRight OnlyL5000 Base Layer Density: ---Soft 35A EVA55A Multicork Top Cover: ---1/8in. P-Cell1/16in. Poron, 1/16in. P-Cell1/16in. Poron, 1/8in. P-Cell Metatarsal Pads: ---RightLeftBoth Medial Flange: ---RightLeftBoth Lateral Flange: ---RightLeftBoth Special Instructions: Click to download image SCANS Please email scans to scans@protosthetics.com