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

    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: