Rx Order Forms

ORTHOTIC LAB ,LLC

 Account_________________________   PO#_________Phone#___________

City__________________St____Zip_________

Patient Name_________________________  Gender M  F  Age _____

Weight________ Shoe Size _________ Shoe Style  _________  Call me 

Orthotic Profile  N-Sport  N-Dress  Reg  High  N-Cobra  N-Control (Shaffer)  N-Soccer / Cleats  N-Skate / Ski	Shell Material  Polypropylene 1/8 (STD)  Polypropylene 3/16 Graphite Pelite/Eva (Soft, 35) Pelite/Eva (Firm, 50+) Subortholene 1/8 _____	Shell Mods   Left Right Fill Arch Left Right First Met Cutout Left Right First Ray Cutout  Left Right Flange Lat Med  Lt Rt Gait Plate In Out  Lt Rt Heel Spur Hole Left Right	Shell Width  Narrow (Bisect 1st & 5th)  Medium (Bisect 1st Outside 5th)  Wide (Outside 1st & 5th)
Post Heel Lab Discretion  Extrinsic  Intrinsic Right: Medial_____Lateral_____ Left: Medial_____Lateral_____	Post Forefoot  Lab Discretion  Extrinsic  Intrinsic Right: Medial_____Lateral_____ Left: Medial_____Lateral_____	Heel Cup  Low (8mm  Standard (12mm)  Deep (15mm)  X-Deep (18mm)	Heel Lift (enter amount) Right_____ Left _____
		Pronation Skive Heel Post  Corner Skive only (STD)  Skive 1/3 medial post surface  Left  Right	Kirby Skive (cast mod) (enter amount 2mm-6mm) Right _____ Left _____
Cover Length  3/4 Cover Shell  7/8 To Sulcus  Full length	Top Cover  Vinyl  1/8 Pelite/Eva  1/16 Spenco  1/8 Spenco	Cushion (Same length as cover)  1/16 PPT/Poron  1/8 PPT/Poron  1/8 Pelite/Eva	Add Forefoot Cushion  1/16 PPT/Poron  1/8 PPT/Poron  1/8 Pelite/Eva Dancer PadLeft Right
Metatarsal Pads  Left  Low 1/16  Right  Medium 1/8  Soft  Firm  High 3/16	Met Pad Width  Narrow (Inside2 & 4)  Medium (Bisect 2& 4)  Wide (Outside 2 & 4) NeuromaPad(as marked)	Morton’s Extension  Left  Right Reverse Morton’s  Left  Right Tendon Relief Track  Left  Right	Heel Padding  Full 1/8”  Horseshoe Extend Pad Proximal to Navicular  Cuboid 
		 Digit Cutout   Rt  1 2 3 4 5                             Lt  1 2 3 4 5  Cutout w/“U”  Rt  1 2 3 4 5                            Lt  1 2 3 4 5        Navicular Relief Left Right

Send Address Labels  Rx forms  Info on Ritchie and Arizona Braces  Info on 3D Scanner Program

Add Instructions:

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Physcian's Signature Required: ____________________________Date:_____/______/________

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