Mile High Orthotics Lab, Inc. 4970 Monaco Street, Commerce City, CO 80022

Phone: 866-710-4880 fax: 303-288-3687

C U S T O M F O O T W E A R O R D E R F O R M

FACILITY NAMEFACILITY NAMEFACILITY NAMEFACILITY NAME: : : : Purchase Order # Date: / /

SHIP ADDRESSSHIP ADDRESSSHIP ADDRESSSHIP ADDRESS: : : : BILL ADDRESSBILL ADDRESSBILL ADDRESSBILL ADDRESS::::

City: State: Zip: City: State: Zip: Tel # Fax Tel # ( ) Fax # ( ) Contact: Title: Contact: Title:

PATIENT NAME:PATIENT NAME:PATIENT NAME:PATIENT NAME: . Ì Male Ì Female Weight: Age:

Activity level: Ì Non Ambulatory Ì Low / transfer Ì Medium Ì High / active Occupation:. Ì Currently Wearing Custom Shoes Company: Height: Information:. Rx / Diagnosis:

PLEASE MARK AREAS OF SPECIAL ATTENTION ON THE PICTURES BELOW PLEASE MARK AREAS OF SPECIAL ATTENTION ON THE PICTURES BELOW PLEASE MARK AREAS OF SPECIAL ATTENTION ON THE PICTURES BELOW PLEASE MARK AREAS OF SPECIAL ATTENTION ON THE PICTURES BELOW !!!! AND ON THE CAST AND ON THE CAST AND ON THE CAST AND ON THE CAST L R LEFT RIGHT LEFT RIGHT

FOOT STRUCTUREFOOT STRUCTUREFOOT STRUCTUREFOOT STRUCTURE Normal

Flaccid Rigid

ANKLE RANGE OF MOTIONANKLE RANGE OF MOTIONANKLE RANGE OF MOTIONANKLE RANGE OF MOTION Normal

Fixed Limi ted

WEIGHT BEARING TOE WEIGHT BEARING TOE WEIGHT BEARING TOE WEIGHT BEARING TOE POSITIONPOSITIONPOSITIONPOSITION Normal

Turned-Up Turned-Down

Overlap or Hammered NONNONNONNON----WEIGHT BEARING TOE POSITIONWEIGHT BEARING TOE POSITIONWEIGHT BEARING TOE POSITIONWEIGHT BEARING TOE POSITION

Normal Turned-Up

Turned-Down Overlap or Hammered

R L L R

PLEASE MARK AREAS FOR RELIEF OR SPLEASE MARK AREAS FOR RELIEF OR SPLEASE MARK AREAS FOR RELIEF OR SPLEASE MARK AREAS FOR RELIEF OR SPECIAL ATTENTIONPECIAL ATTENTIONPECIAL ATTENTIONPECIAL ATTENTION

CAST MODIFICATIONSCAST MODIFICATIONSCAST MODIFICATIONSCAST MODIFICATIONS L RL RL RL R L RL RL RL R EXTRA HIGH TOE BOXEXTRA HIGH TOE BOXEXTRA HIGH TOE BOXEXTRA HIGH TOE BOX DEPRESS AS MARKEDDEPRESS AS MARKEDDEPRESS AS MARKEDDEPRESS AS MARKED EXTRA TOE ELONGATIONEXTRA TOE ELONGATIONEXTRA TOE ELONGATIONEXTRA TOE ELONGATION SNUG HEELSSNUG HEELSSNUG HEELSSNUG HEELS CORRECT CAST TO 90CORRECT CAST TO 90CORRECT CAST TO 90CORRECT CAST TO 90ْْ PROSTHETIC FOOT CASTEDPROSTHETIC FOOT CASTEDPROSTHETIC FOOT CASTEDPROSTHETIC FOOT CASTED

SHOE STYLE____________ COLOR_______________________ L R L R LOW TOPLOW TOPLOW TOPLOW TOP LACELACELACELACE CHUKKACHUKKACHUKKACHUKKA VELCRO ______ PER SHOEVELCRO ______ PER SHOEVELCRO ______ PER SHOEVELCRO ______ PER SHOE HIGH TOPHIGH TOPHIGH TOPHIGH TOP SPEED EYELETS SPEED EYELETS SPEED EYELETS SPEED EYELETS ______ PER SHOE ______ PER SHOE ______ PER SHOE ______ PER SHOE

SEMISEMISEMISEMI----SURGICAL OPENINGSURGICAL OPENINGSURGICAL OPENINGSURGICAL OPENING HOOKS ______ PER SHOEHOOKS ______ PER SHOEHOOKS ______ PER SHOEHOOKS ______ PER SHOE

SURGICAL OPENINGSURGICAL OPENINGSURGICAL OPENINGSURGICAL OPENING

PADDED COLLARSPADDED COLLARSPADDED COLLARSPADDED COLLARS

PADDED TONGUESPADDED TONGUESPADDED TONGUESPADDED TONGUES

L R INSERTS L R AMPUTATION FILLERS ¼” PINK + ¼”¼” PINK + ¼”¼” PINK + ¼”¼” PINK + ¼” WHITE WHITE WHITE WHITE MOLDED PROSTHETIC FILLERMOLDED PROSTHETIC FILLERMOLDED PROSTHETIC FILLERMOLDED PROSTHETIC FILLER

¼” PINK + ¼” PINK + ¼” PINK + ¼” PINK + ⅛” PORON + ¼” WHITE” PORON + ¼” WHITE” PORON + ¼” WHITE” PORON + ¼” WHITE NONNONNONNON----MOLDED TOE FILLERMOLDED TOE FILLERMOLDED TOE FILLERMOLDED TOE FILLER ¼” PINK + ¼” PINK + ¼” PINK + ¼” PINK + ⅛” PORON + ¼” CORK” PORON + ¼” CORK” PORON + ¼” CORK” PORON + ¼” CORK MATCH SOUND SIDEMATCH SOUND SIDEMATCH SOUND SIDEMATCH SOUND SIDE

¼” PINK + ¼” EVA¼” PINK + ¼” EVA¼” PINK + ¼” EVA¼” PINK + ¼” EVA SHORTER THAN SOUND SIDE SHORTER THAN SOUND SIDE SHORTER THAN SOUND SIDE SHORTER THAN SOUND SIDE

¼” PINK + ¼” PINK + ¼” PINK + ¼” PINK + ⅛” PORON + ¼” EVA” PORON + ¼” EVA” PORON + ¼” EVA” PORON + ¼” EVA L R ELEVATIONS L R SOLES HEELHEELHEELHEEL ON INSON INSON INSON INSERT(S)ERT(S)ERT(S)ERT(S) HEAVY DUTY WEIGHTHEAVY DUTY WEIGHTHEAVY DUTY WEIGHTHEAVY DUTY WEIGHT BALLBALLBALLBALL ON SOLEON SOLEON SOLEON SOLE WEDGE SOLEWEDGE SOLEWEDGE SOLEWEDGE SOLE TOETOETOETOE IN ADDITION TO ¾” HEELIN ADDITION TO ¾” HEELIN ADDITION TO ¾” HEELIN ADDITION TO ¾” HEEL AMERICAN SOLEAMERICAN SOLEAMERICAN SOLEAMERICAN SOLE TOTAL RAISETOTAL RAISETOTAL RAISETOTAL RAISE ROCKER SOLES (FORE FOOT)ROCKER SOLES (FORE FOOT)ROCKER SOLES (FORE FOOT)ROCKER SOLES (FORE FOOT)

ROLLER SOLES (HEEL AND FOREFOOT)ROLLER SOLES (HEEL AND FOREFOOT)ROLLER SOLES (HEEL AND FOREFOOT)ROLLER SOLES (HEEL AND FOREFOOT)

SPECIAL INSTRUCTIONS "PLEASE CALL FOR CONSULT BEFORE PROCESSING