Home » Order 1. Practitioner Information Name: Address: City: State: Zip: 2. Patient Information Name: Sex: female male Age: Weight: Sport or Occupation: Usual Footwear: Heel Height: Shoe Size: Shoe Width: N M W Arch Height--Non-Weight Bearing very high high normal low flat Arch Height--Weight-Bearing very high high normal low flat Foot Motions LEFT: flexible normal restricted rigid RIGHT: flexible normal restricted rigid Please describe any lesions that will need to be accommodated for: Toe Crest Pad 2-4 Met Pad Met Bar Pad Heel Cushion Neuroma Pad Scaphoid Pad Dancer's Pad Mortons Extension Heel Spur Pad Neuroma Plug left right both 3. Prescription Positive Cast Correction: No plaster arch fill (high arch orthotic) Medium plaster arch fill (medium arch orthotic) Maximum plaster arch fill (low arch orthotic) Other: (please describe) 4. Posting Post to Lab discretion according to casts Rearfoot Posting: yes_extrinsic yes_intrinsic no Right: degrees varus vertical motion Left: degrees varus vertical motion Forefoot Posting: intrinsic extrinsic (Posted intrinsic unless otherwise specified) Right: degrees varus valgus Left: degrees varus valgus 5. Orthotic Type (indicate choice) Sport Orthotics Sport Star I Sport Star II Sport Star III Sport Star IV Sport Device (plain) Direct Sport Pro--please indicate style: flexible semi-flexible semi-rigid Rigid Orthotics Polydur Polydur with fiberglass Shaffer (Polydur) CEO (TL-61) Children's Orthotics Out-Toe-Gait-Plate Whitman Roberts Heel Stabilizers--type: Geriatric Orthotics Geriatric - Flexible Poly Propylene--please specify: Plain Deluxe Active - Indicate length: flex control Flex Star - Indicate length: MP Sulcus Full Fashion Orthotics CEO Heels (TL-61) Princess Poly Heels Comfort Flex Comfort Flex with cut out Accommodative Orthotics Standard Leather Shell - specify: Buildup Reinforce with Thermo HK Direct Mill - specify: ultra soft plastizote soft puff medium EVA firm cork MP Sulcus Full Diabetic Orthotics Soft Luna Medium Luna Firm Luna Standard with 1/8" Plastizote Cover. Full length or indicate other choice below. 6. Width Narrow Medium Wide 7. Customizing Extensions: Sulcus Full Length Plain Closed Cell Neoprene Pelite Spenco Plastizote KOREX 1/16" PPt 1/8" PPt 1/16" Vylite 1/8" Vylite Type Covers: MP Sulcus Full Spenco Sweat Resistant Cowhide Naugahyde Pelite 1/16" PPt 1/8" PPt Padded Naugahyde 1/16" Neolon Horsehide Plastizote 1/16" Vylite 1/8" Vylite Suede Brown Type Suede Bottom Cover 8. Special Instructions Type any special instructions here Thank you for your order! Click Submit to send to North Star Podiatric via e-mail.
Home » Order
Name:
Address:
City:
State:
Zip:
Sex: female male
Age:
Weight:
Sport or Occupation:
Usual Footwear:
Heel Height:
Shoe Size:
Shoe Width: N M W
Arch Height--Non-Weight Bearing
very high
high
normal
low
flat
Arch Height--Weight-Bearing
Foot Motions
LEFT:
flexible
restricted
rigid
RIGHT:
Please describe any lesions that will need to be accommodated for:
Toe Crest Pad
2-4 Met Pad
Met Bar Pad
Heel Cushion
Neuroma Pad
Scaphoid Pad
Dancer's Pad
Mortons Extension
Heel Spur Pad
Neuroma Plug
left right both
Positive Cast Correction:
No plaster arch fill (high arch orthotic)
Medium plaster arch fill (medium arch orthotic)
Maximum plaster arch fill (low arch orthotic)
Other: (please describe)
Post to Lab discretion according to casts
Rearfoot Posting: yes_extrinsic yes_intrinsic no
Right: degrees varus vertical motion Left: degrees varus vertical motion
Forefoot Posting: intrinsic extrinsic (Posted intrinsic unless otherwise specified)
Right: degrees varus valgus Left: degrees varus valgus
Sport Star I Sport Star II Sport Star III Sport Star IV Sport Device (plain) Direct Sport Pro--please indicate style: flexible semi-flexible semi-rigid
Polydur Polydur with fiberglass Shaffer (Polydur) CEO (TL-61)
Out-Toe-Gait-Plate Whitman Roberts Heel Stabilizers--type:
Geriatric - Flexible Poly Propylene--please specify: Plain Deluxe
Active - Indicate length: flex control
Flex Star - Indicate length: MP Sulcus Full
CEO Heels (TL-61) Princess Poly Heels Comfort Flex Comfort Flex with cut out
Standard Leather Shell - specify: Buildup Reinforce with Thermo HK
Direct Mill - specify: ultra soft plastizote soft puff medium EVA firm cork MP Sulcus Full
Soft Luna Medium Luna Firm Luna
Standard with 1/8" Plastizote Cover. Full length or indicate other choice below.
Narrow Medium Wide
Extensions:
Sulcus Full Length Plain Closed Cell Neoprene Pelite Spenco Plastizote KOREX 1/16" PPt 1/8" PPt 1/16" Vylite 1/8" Vylite Type
Covers:
MP Sulcus Full Spenco Sweat Resistant Cowhide Naugahyde Pelite 1/16" PPt 1/8" PPt Padded Naugahyde 1/16" Neolon Horsehide Plastizote 1/16" Vylite 1/8" Vylite Suede Brown Type Suede Bottom Cover
MP Sulcus Full Spenco Sweat Resistant Cowhide Naugahyde Pelite 1/16" PPt 1/8" PPt Padded Naugahyde 1/16" Neolon Horsehide Plastizote 1/16" Vylite 1/8" Vylite Suede Brown Type
Suede Bottom Cover
Type any special instructions here
