Practitioner
Name:
Email:
Phone:
Clinic:
Address:

Patient
Patient Name:
Date:

Return required
StandardExpress
Required Return Date:

Design - (Info)

5° Midfoot5° Midfoot Plus12° Rearfoot Wedge

Density - (Info)

SuperFlexExtraFlexFlexRigidUltraRigid

Size (mm) - (Info)

A(105)B(115)C(125)D(135)E(145)F(155)G(165)H(175)I(185)J(195)K(205)L(215)

Grind - (Info)

NormNarrowCourtHookHook(full heel cover)

Additions - (Info)
Left/Right
L
R
Eva Rearfoot Post:
Left
Right
Heel Cup Depth:

(12mm or lower)

Heel Lift (mm):
FHSA:
Left
Right

*From heel spur accommodation

Met Dome:
Left
Right
1st MPJ Cutout:
Left
Right
1st Ray Cutout:
Left
Right
Poron PFA (mm):
Mortons Extension:
Left
Right
Poron/Eva:
Medial Flange:
Left
Right
Lateral Flange:
Left
Right
Arch Fills:
Left
Right
Eva or Poron:
Calcaneal Cutout(mm):

Cover Length Clear - (Info)

MetsSulcusF/L

Poron Clear - (Info)

1.6mm3.2mm6.4mm

ShellExtensionS&E

Covers Clear - (Info)

AMBEvaLeatherNeopremeNoCoverPerf. EvaPlastiqueSuedeVinylVlies

Size Colour:

Notes for LAB Staff

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