FUNCTIONAL ORTHOTIC ORDER FORM Store ID#: Required field Clinician: Phone: Date: PATIENT NAME First M.I. Last Shoe Size Width Template # Base Layer Left Only Right Only Top Layer Middle Layer (optional) 3/4 Length Male Female Sulcus Full Length Standard (Decreased 1/8” from patient’s cast) Total Contact (Made to patient’s cast) Increased 1/8” from patient’s cast Other CASTING MODIFICATION ADVANCED OPTIONS Quantity Ordered GENDER ARCH HEIGHT TOP LAYER TRIM LINES HEEL POSTINGS Put “1” for neutral post Medial Wedge Left Right mm Medial Wedge mm Lateral Wedge mm Lateral Wedge Heel Lift mm Heel Lift mm mm BASE LAYER MID LAYER 1.5mm Spenco 2mm Poron 3mm Spenco 3mm Poron Semi-Rigid Rigid 1/8” 1/8” 1/16” Polypropylene CoPoly Graphite 3/16” Flexible 1/16” 3/16” 1-877-229-9652 Arch Fitters 1625 SE Hogan Rd, Suite G Gresham, OR 97080 Special Instructions: Contact E-mail: Additional charges may apply 1 2 1 1 1 Pairs 2 High Medial Wall High Lateral Wall 3 3 3 Default 2 Both Left Right NORMAL LOW DRESS Both Right Left DEEP UCBL 1 PLASTAZOTE 25 DM 35 DM 20 DM 15 DM 20 DM 1mm Black 1mm Brown 1.5mm 25 DM 2mm Lt Blue Puff 2mm Pink 3mm Pink 3mm Pink Puff 3mm Lt Blue Puff 3mm 4.5mm 3mm Blue 2mm Camo Swirl 2mm Pink Puff 2mm Pink Swirl 2mm Blue Swirl 2mm Black Solid 2mm Blue SPENCO (DUAL CLOTH) NAUGAHYDE 35 DM 3mm Camo Swirl 3mm Pink Swirl 3mm Blue Swirl 3mm Black Solid MICROCELL PUFF MET-PAD Left Both Right Medium Medium Bar Wide Wide Bar Medium Medium Bar Wide Wide Bar Medium Medium Bar Wide Wide Bar STANDARD AGGRESSIVE HEEL CUP HEIGHT
Transcript
FUNCTIONAL ORTHOTIC ORDER FORM
Store ID#:
Required field
Clinician: Phone: Date:
PATIENT NAME First M.I. Last
Shoe Size Width Template #
Base Layer
Left Only Right Only
Top Layer
Middle Layer (optional)
3/4 Length
Male Female
SulcusFull Length
Standard (Decreased 1/8” from patient’s cast)
Total Contact (Made to patient’s cast)
Increased 1/8”from patient’s cast Other
CASTING MODIFICATION
ADVANCED OPTIONS
Quantity Ordered
GENDER
ARCH HEIGHT
TOP LAYER
TRIM LINES
HEEL POSTINGS
Put “1” for neutral post
Medial Wedge
Left Rightmm Medial Wedge mm
Lateral Wedge mm Lateral Wedge
Heel Lift mm Heel Lift
mm
mm
BASE LAYER
MID LAYER
1.5mm Spenco 2mm Poron
3mm Spenco 3mm Poron
Semi-RigidRigid
1/8” 1/8” 1/16”
Polypropylene CoPoly Graphite
3/16”
Flexible 1/16”
3/16”
1-877-229-9652 Arch Fitters 1625 SE Hogan Rd, Suite G Gresham, OR 97080
Special Instructions:
Contact E-mail:Additional charges may apply1
21
1
1
Pairs 2
High Medial Wall
High Lateral Wall
3 3
3Default 2
Both Left Right
NORMAL
LOW
DRESS
Both RightLeft
DEEP
UCBL
1
PLASTAZOTE
25 DM
35 DM
20 DM
15 DM
20 DM
1mm Black 1mm Brown
1.5mm25 DM
2mm Lt Blue Pu�
2mm Pink 3mm Pink
3mm Pink Pu�
3mm Lt Blue Pu�
3mm 4.5mm
3mm Blue
2mm Camo Swirl
2mm Pink Pu�
2mm Pink Swirl
2mm Blue Swirl
2mm Black Solid
2mm Blue
SPENCO (DUAL CLOTH)
NAUGAHYDE
35 DM
3mm Camo Swirl
3mm Pink Swirl
3mm Blue Swirl
3mm Black Solid
MICROCELL PUFF
MET-PADLeftBoth Right
Medium
Medium
Bar
Wide
Wide
Bar
Medium
Medium
Bar
Wide
Wide
Bar
Medium
Medium
Bar
Wide
Wide
Bar
STANDARD
AGGRESSIVE
HEEL CUP HEIGHT
1625 SE Hogan Rd Suite G, Gresham, OR 97080 Phone: 877-229-9652 Fax: 503-489-0706
www.archfitters.com
*Additional charges may apply, see your pricing plan for details or call 877-229-9652.
