Orthotic script | Prescription

Company name

Date

Podiatrist Name

Email

Patient Name

Patient Shoe Size (US Men/Women)

If full length orthotic, what shoe type for fitting (ie. HOKA runner)

Heel Design

Traditional

Wedge

Rear foot RIGHT Correction

Rear foot LEFT Correction

Forefoot RIGHT Correction

Forefoot LEFT Correction

Arch Style

Mid

Mod

As is 0 deg

Arch Fill

Standard 10% reduction

Min Arch Fill

Max Arch Fill

Other Specific arch height (add to notes)

Density

Extra Soft

Soft

Medium

Firm

Orthotic length

Full

Sulci

3/4

Modifications RIGHT

Modifications LEFT

Padding (intrinsic build)

Any additional comments, modifications or notes

Email foot scans (right and left) to hello@eprintorthotics.com

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