please have c.ped determine shoe size · please have lab determine accommodations met bar met pad...

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. Leﬅ Quanty Right Quanty 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 LT EV .75 CP PP 1 st 2 nd 3 rd 4 th 5 th 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 SA FA CV SC AF LF _______ 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

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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

L R L R

IRL

FLM

FLL

See other sheet

LTEV.75CPPP