Semi Custom Orthotic script

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Customisations
Custom Orthotic script
Semi Custom Script
T & C's

CONTACT

Company name

Date

Podiatrist Name

Email*

Patient Name

Patient Shoe US SIZE*

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

Heel Design

Traditional

Wedge

Arch Fill

Mid

Mod

As is 0deg

Other

Arch heigh mm*

Rear foot correction RIGHT

Rear foot correction LEFT

Density

Extra Soft

Soft

Medium

Firm

Orthotic length

Full

Sulci

3/4

Modifications RIGHT

Met Dome

Medial Skive

Lateral Skive

Cuboid Notch

Extra Heel Expansion

1st Ray Accom

Gait Plate

Plantar Fascial Accomodation

Medial Flare

Accomodations (drops) - please note where and depth

1st MTPJ Cut Out

Modifications LEFT

Met Dome

Medial Skive

Lateral Skive

Cuboid Notch

Extra Heel Expansion

1st Ray Accom

Gait Plate

Plantar Fascial Accomodation

Medial Flare

Accomodations (drops) - please note where and depth

1st MTPJ Cut Out

Padding (intrinsic build)

Any additional padding such as PMP, Metbar, Cobra Pad etc.

Any additional comments, modifications or notes

Prescription form double checked

You agree to terms and conditions and authorise the charge of orthotic on credit card once form submitted

Home
About
Customisations
Custom Orthotic script
Semi Custom Script
T & C's

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