Met Bar
Met Pad
Relief (cut out) – as marked on imprint
Morton’s Extension_________
Heel Lift on Insert (1/4 inch max.) Height ____
______ Medial Wedge on Insert
______ Lateral Wedge on Insert
Dancer’s Pad____________________
Saddle Pad (U Pad)
Heel Cushion
Charcot Accommodation (A5513)
Cavus Foot (A5513)
SureFit/SPS Acct Number: Ship to Location:
Customer PO#: Date:
Contact/Name: TEL: 800.298.6050 FAX: 888.801.3450
Patient ID: Gender: Male / Female
-Required Information! If incomplete, inserts will be made longer & wider for in clinic adjustments
Shoe SKU#: Lace Velcro
Length: Width:
Custom Insert Order Information
INSERTS ONLY-Preferred Method [Trim to shoes above] Order inserts directly from SureFit - not through HD
Inserts & Shoes-optional method [Order shoes above] Turn around time is dependent on warehouse shoe inventory. NOTE: Notification of a backorder will be delayed.
Left Quantity Right Quantity
Tri-Lam EVA 50 Shor A Base Recommended cork base alternative
Note: Toe Fill (L5000); Non-Toe Filler Combo Inserts are (A5513) Left Missing Toes Right Missing Toes
Left Right (FOR SUREFIT’S INTERNAL LAB USE ONLY)
M TFC
RL LEFT
MF
L R L R
IRL
FLM
FLL
DC
See other sheet
SN
LTEV.75CPPP
1st 2nd 3rd 4th 5th
L R
1 2 3 4 5
SureFit 4050 NW 126th Ave, Suite 110, Coral Springs, FL 33065
1 2 3 4 5
1st 2nd 3rd 4th 5th
SFDI V2 10/2020
HFN
SAFACVSCAFLF
_______
Cork Base Trilam Standard
Toe Fill Custom Cork Insert w/Fill
Bi-Lam EVA 35 Shor A Base Tri-Lam EVA 35 Shor A Base
_______
_______
_______
_______
_______
_______
Cell #:
_______
SPECIAL INSTRUCTIONS
_______
_______
P TF L R L R
RL RIGHT
Select for toe fills only Select for toe fills only
