Custom orthotiCs PresCriPtion Form
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
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