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.