test-form

    Practitioner
    Name:
    Email:
    Phone:
    Clinic:
    Address:
    Patient
    Patient Name:
    Date:
    Return required
    Standard
    Express
    Required Return Date:
    Design

    5° Midfoot
    5° Midfoot Plus
    12° Rearfoot Wedge

    Density

    Super Flex
    Extra Flex
    Flex
    Rigid
    Ultra Rigid

    Size (mm)
    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
    Norm
    Narrow
    Court
    Hook
    Hook (full heel cover)
    Additions
    Left/Right
    L
    R
    Eva Rearfoot Post:
    Heel Cup Depth:

    (12mm or lower)

    Heel Lift (mm):
    FHSA:

    *From heel spur accommodation

    Met Dome:
    1st MPJ Cutout:
    1st Ray Cutout:
    Poron PFA (mm):
    Mortons Extension:
    Poron/Eva:
    Medial Flange:
    Lateral Flange:
    Arch Fills:
    Eva or Poron:
    Calcaneal Cutout(mm):
    Cover Length
    Mets
    Sulcus
    F/L
    Poron
    1.6 mm
    3.2 mm
    3.2 mm
    Shell
    Extension
    S&E
    Covers
    Vinyl
    Leather
    AMB
    Neopreme
    Suede
    EVA
    Pere Eva
    PB Vlies
    Plastique
    No Cover

    Size Colour:

    Notes for LAB Staff

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