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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