Semi Custom Orthotic script

Company name

Postage Address

Date

Day

Month

Year

Podiatrist Name

Email

Patient Name

Patient Shoe Size - US or EU

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

Arch height mm

Rear foot correction RIGHT

Rear foot correction LEFT

Padding (intrinsic build)

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

Top cover - please note extra fee for pair

Black Vinyl Top Cover ($10)

1.6mm Black EVA ($20)

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