Prescription Form
535 N 1300 E St George, Utah 84770 (800) 301-5835 Phone: (435)-251-8506 (435) 251-8505 Fax: www.fdmotion.com Lab to Call Doctor Date _____________________________ Date Received in Lab___________________________________ Printing Information Patient Name: M F Weight: Age: Shoe Size: Occupation Symptoms/Diagnosis Please place your pre printed account labels here, or fill in the information Doctor's Name: Doctor's Address: City State Phone Fax Zip Activity Level: Shoe Type: Products Functional Ortho-Sport These devices are made to lab standard Premium Ultra Dress Ultra Dress II Athletic Walker Tri Trainer Accommodative / Diabetic Diabetic Medium Diabetic Comfort (soft) Soft Support Standard Support Firm Support Children's UCBL Whitman Roberts Gait Plates Out toe In toe Check boxes below for additional accommodations Performance RX Semi Flex Semi-Rigid Rigid Type: Fore Foot Standard Intrinsic No Post Root Extrinsic L _____ Varus/Valgus Top Cover Material EVA Vinyl Leather Neo-Prime Polypropylene 1/8 3/16 Cast & Grind Instructions Heel Cup Orthotic Width Shallow (10mm) Narrow Regular (12mm) Normal Wide/ Athletic Cut Deep (16mm) Other _____________ Posting Rear Foot Standard No Post Modified Intrinsic Extrinsic Left Heel Lift __ mm Flanges Medial Lateral Mild Arch Height Standard Low Med High Posting Shell Material TL 2100 Semi Flex Semi-Rigid Rigid Right L _____ Varus/Valgus R_____ Varus/Valgus Pronation Skive __ Deg Kirby Skive ________MM Covering Top Cover Length Padding Length Thickness Shell Only Forefoot Only 1/8 Sulcus Extension Only 1/16 Full Length Entire Device R_____ Varus/Valgus Poron P-Cell / Poron Met Pad Met Bar Arch Pad Left Left Left Right Right Right 1st Ray cut Out Morton's Extension Left Left Right Right Accommodations Heel Spur Accommodation: Left Right Horseshoe Pard Heel Cushion Other Accommodations: Neuroma Pad Amputee Sponge Fill Cuneiforme Metatarsal Accommodations Reverse Right 1 2 3 Left 1 2 3 Additional Comments RIGHT LEFT Please return top copy and retain bottom copy for your records. 4 4 5 5 535 N 1300 E St George, Utah 84770 (800) 301-5835 Phone: (435)-251-8506 (435) 251-8505 Fax: www.fdmotion.com Date _____________________________ Lab to Call Doctor Date Received in Lab___________________________________ Printing Information Patient Name: M F Weight: Age: Shoe Size: Occupation Symptoms/Diagnosis Please place your pre printed account labels here, or fill in the information Doctor's Name: Doctor's Address: City State Phone Fax Zip Activity Level: Shoe Type: Grossman - $99 These devices are made to lab standard Everyday Athletic Check boxes below for additional accommodations Shell Padding 1/8 3/16 Grind 1/16 FF Only 1/8 FF Only Met Pad Met Bar No Arch Pad Left Left Left Right Right Right 1st Ray cut Out Morton’s Extension Left Left Right Right Top Covers Wide Narrow Length Vinyl Leather Eva Left Left Left Horseshoe Pad Heel Cushion Neuroma Pad Met Sulcus Full Right Right Right Metatarsal Accommodations Right 1 2 Left 1 2 Reverse 3 3 4 4 5 5 4 4 5 5 Foot Essentials - $65 - No Printing Available These devices are made to lab standard Smart Support Smart Dress Smart Basic Smart Sport Smart Dress 1 Check boxes below for additional accommodations Arch Grind Low Medium High No Arch Fill Posting Top Covers Wide Narrow Full Sulcus Met 1/8 1/16 Fore Foot Standard Intrinsic Rear Foot No Post Extrinsic Standard Modified Intrinsic Heel Lift____mm L________Varus/Valgus R________Varus/Valgus Accommodations Met Pad Met Bar Neuroma Pad Left Left Left Right Right Right 1st Ray cut Out Morton’s Extension Left Left Right Right L________Varus/Valgus R________Varus/Valgus Left Left Left Horseshoe Pad Heel Cushion Arch Pad Reverse No Post Extrinsic Pronation Skive____Deg Left Right Right Right Right Metatarsal Accommodations Right 1 2 Left 1 2 3 3 Additional Comments RIGHT LEFT Please return top copy and retain bottom copy for your records.
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