Order Form - Orthotic Direct

ORTHOTIC DIRECT
For Office use only
Laboratory
700 Finley Ave., Unit 10, Ajax, Ontario L1S 3Z2
phone: 416-880-6261 fax: 416-849-0496
www.OrthoticDirect.com
CarbonFlex Orthotics
PRACTITIONER/CLINIC INFORMATION
PATIENT INFORMATION
Clinic Name:
NAME :
Tel :
Age / Date of Birth :
Sex :
EXAMINATION FINDINGS
Arch height (non-weight bearing)
Left
Right
Arch height (weight bearing)
Left
Right
High
High
Medium
Medium
Low
Low
Gait
Supination
Left Right
Toe in
Straight
Toe Out
Date in
Date out
Weight:
F
M
ShoeType (Narrow/Wide):
Shoe Size :
SPECIAL INSTRUCTIONS –MARKS ON PLANTAR VIEW
Pronation
Left
Mild
Mild
Moderate
Moderate
Severe
Severe
OPTIONAL FINDINGS
Ankle Dorsi-Flexion General Foot Motion
Left Right
Left Right
Forefoot Varus
Left Right
Forefoot Valgus
Left Right
Adequate
Restricted
Mild
Mild
Limited
Normal
Moderate
Moderate
HyperMobile
Severe
Severe
Hole in Heel
ORDER INFORMATION
L
Rush ($15 additional charge)
Insoles Enclosed
Total # of pairs:
Insoles Tracing Enclosed
Repair/Adjustment ($30 charge )
Shoes Enclosed
ORTHOTICS Support
Morton’s Extension
Metatarsal Pad
L
R
L
R
Reverse Morton’s
Extension
R
L
R
(CarbonFlex)
3/4
FULL LENGTH
ADDITIONS / MODIFICATIONS
SULCUS
Extrinsic Forefoot
Posts
L
R
Forefoot Pad to
Sulcus
L
Balance Pad
R
L
Metatarsal
Accommodation
R
L
R
CASUAL DRESS SPORT DIABETIC U.C.B.L. CHILDREN SANDALS
2.0mm
2.3mm
2.6mm
3.0mm
3.3mm
3.5mm
Heel Cushion Full
Heel Spur Pad
TOP COVER (mark also second choice)
L
L
R
Deep Heel Cup
L
R
Reinforced Arch Fill
R
L
R
Description:
Swatch no:
BOTTOM COVER
Description:
Hard Medial
Flange
Soft Medial
Flange
Swatch no:
L
R
L
1st Metatarsal
Cutout
Heel Raise
L
R
L
R
R
CUSHION
Poron
black
Neolon
black
PPT tan Poron
blue
Plastazote
black
Plastazote
pink
Aerosorb
red
1/16”
1/8”
1/4”
RearFoot Posting
L
R
Hard Lateral Flange
L
R
Lateral RearFoot Skive
L
R
Vinyl Sandwich
L
R
Notes:
Schaphoid Pad
L
R
Met Bar
L
Y shape CrestPad
ToeCrest Pad
L
L
R
Plantar Fasciitis
R
L
R
R
L
R
Out-Toe Gait
Cobra-dress
L
Kinetic Wedge
R
L
R