Toll Free (855) 910-2525
Fax. (321) 202-2819
Email: [email protected]
A Human Biomechanics Company
FOR lab use only
Account #_____________________
Order #_______________________
Receive Date__________________
9561 Satellite Blvd, Suite 300, Orlando, FL, 32837
Custom Orthotics Prescription Form
Office Name____________________________________________
Doctor’s Name__________________________________________
Address________________________________________________
________________________________________________
Shipped Date__________________
☐ Rush Service - 3 Days
Date ______/_____________/2014
Phone (_____) _________________
Patient Information
Patient’s Name___________________________________________ Age_______ Height _________
Weight: _________lbs (_________kg)
Gender:
M
F
Shoe Size________
Shoe Style:
Dress
Athletic
Casual Industrial High Heel _____in (_____mm)
Foot Posture:
Normal,
Cast Taken: Pronated
Non Weight Bearing TYPE OF ORTHOSIS
SPORTS ACTIVITIES
Hiker
Runner (Rigid Shell)
Shell,
Bodybuilder ( Rigid
Recommended over 190 lb.)
Rapid Sport (Rigid Shell)
Sport Flex (Soft Base)
(Soft Base)
moderate activity / Dress
Men’s Dress (Rigid Shell)
Woman’s Dress (Rigid Shell)
High Heel Shoes,
Cobra ( For
)
Rigid Shell
Low activity / Casual
ADL Activities for Daily Living
ADL after 65
DIABETIC
Base D-40,
)
A5513 / A1000 ( Soft
Plastazote 1/8 on top
R
L
Both
children
☐ Universal Pediatric
☐ Rigid ☐ Soft
☐ Heel Stabilizer ☐ Rigid ☐ Soft
☐ U.C.B.L.
☐ Rigid ☐ Soft
Whitman
R
L
Both,
Supinated
Semi Weight Bearing LENGTH OF ORTHOSIS
Met
Sulcus
Full Extension
SPECIAL TOPCOAT REQUESTS
Spenco - equivalent
1/8”
1/16”
Ortho Leather
Diabetic (Platazote 1/8”)
POSTING INSTRUCTIONS
Post to Cast
☐ Rearfoot
☐ Extrinsic ☐ Intrinsic
Right
Left
___° Varus
___° Varus
___° Valgus
___° Valgus
☐ Forefoot
☐ Extrinsic ☐ Intrinsic
Right
Left
___° Varus
___° Varus
___° Valgus
___° Valgus
Notes & Comments: _______________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Customize Wording (logo) on Top Cover:
Use Your “MyTrufit” Account to upload
your practice logo or text inscription.
(space is limited Height: 1 1/4” Width: 3”)
R
L
Both
Weight Bearing
Accommodations
☐ Heel Lift
___R mm ___ L mm
Deep Heel Cup
☐ Heel Pad
☐R ☐L
☐ Heel Spur Cutout with
Foam Disk
☐R ☐L
Reinforced Arch
(Greater than 190 lbs)
Metatarsal Pads on Both
☐ Neuroma Pad
☐R ☐L
☐ Morton’s Extension
☐R ☐L
☐ 1st Ray Cutout
☐R ☐L
☐ 1st Met Clip
☐R ☐L
☐ Balance for Lesions
“as marked on cast”
☐R ☐L
R L
Indicate Spurs & Lesions
E
SA
L
MP