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TABLE OF CONTENTS
Women’s Premiere Collection
Medical Collection
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CUSTOM-MADE ORTHOTICS ORDER FORM
APIS FOOTWEAR 2239 Tyler Ave, S El Monte, CA 91733 Tel: (888)937-2747 Fax: (888)990-2245
Contact:
P.O. No.:
Bill To:
Acct#
Address:
Ship To:
City:
State & Zip:
Address:
City:
State & Zip:
Ship Via: … UPS 1 day / 2 day / 3 day / Ground … US MAIL … FEDEX 1 day / 2 day / Ground
Patient Name:
Shoe Style:
Shoe Size (L):
Sex: … Male … Female
Weight:
Color:
(R):
… Check if you want to order shoes
Height:
DIAGNOSIS (diabetic, neuropathy, edema, ankle/
INSERT
SPECIFICATIONS
(quantity, material, etc)
Right
Left
Mark prominent areas for off-loading
OTHER SPECIFICATIONS
This form can be downloaded from http: //www.apisfootwear.com/customshoes.htm
54
CUSTOM-MADE SHOES ORDER FORM
APIS FOOTWEAR 2239 Tyler Ave, S El Monte, CA 91733 Tel: (888)937-2747 Fax: (888)990-2245
Contact:
P.O. No.:
Bill To:
Acct#
Address:
Ship To:
City:
State & Zip:
Address:
City:
State & Zip:
Ship Via: … UPS 1 day / 2 day / 3 day / Ground … US MAIL … FEDEX 1 day / 2 day / Ground
Patient Name:
Shoe Style:
Sex: … Male … Female
Shoe Size (if not custom) (L):
Weight:
Shoe Closure: … Lace … Velcro
Height:
Color:
(R):
DIAGNOSIS (diabetic, neuropathy, edema, ankle/toe
LEFT FOOT
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instep
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RIGHT FOOT
SHOE MODIFICATIONS
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Foot length:
Circumferences:
Ball width:
ball
instep
INSERT SPECIFICATIONS
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This form can be downloaded from http: //www.apisfootwear.com/customshoes.htm
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