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

Top