re-cover prescription form - ortesi
TRANSCRIPT
240mm
250mm
260mm
270mm
280mm
PODIATRIST INFORMATIONName
Clinic
Address
Phone
ORTHOTIC TYPETraditional Concave Wedge Wedge Court Hook Full Heel
ORTHOTIC SHELL OPTIONSPolypropylene 2.5mm 3.0mm 4.0mm 4.7mm
EVA 190 220 330 400
Dual EVA 190/220 190/330 220/330 220/400
PolyCarbon 2.2mm 2.5mm 3.2mm 4.0mm
Other
Width Narrow Standard Wide
Length Short Standard Long
ARCH Mid. Foot High Arch Device
Modified Root Standard Arch Device
Inverted Low Arch Device
ORTHOTIC COVER OPTIONSStandard Shell Length
Standard Plus Shell Length and Poron
Web* Sulcus Length and Poron - to web-space
Performance* Full Length and Poron - to the end of shoe
Full Length EVA Full Length EVA Shell - to end of shoe
Vinyl Colour
Cover Lunasoft Colour
Spenco 1.5 Spenco 3.0 Colour
Other
Mid Layer Poron 1.5 (Blue) Poron 3.0 (Blue) Poron 3.0 (Red)
Other
*All extensions have a Camberelle base as standard
PATIENT INFORMATIONName
Shoe Type Shoe Size
Age M / F Weight kg
DATESOrder Date / / Issue Date (opt) / /
Return Standard (Within 6 Business Days) Rapid (Within 3 Business Days)
CORRECTIONSLEFT RIGHT
Rear Foot Correction
Fore Foot Correction
MODIFICATIONS AND ADDITIONSLEFT RIGHT
Medial Skive mm mm
Lateral Skive mm mm
Heel Lift mm mm
Heel Cup Height mm mm
Extra Heel Expansion mm mm
Plantar Fascial Accommodation mm mm
Cuboid Notch mm mm
1st Ray Cut Out
Low Bulk Grind
Heel Stabiliser (EVA Post)
Heel Stabiliser (Intrinsic)
Met Dome
Met Pad
Heel Aperature
No Plaster Fill on Fore Foot 2-4
Medial Flare
Medial Wrap
Full Foot Contact
Other
R
L
L
L
R
R
R
L
GENERAL NOTES
INV INV
EV EV
INV INV
EV EV
FOOTLINK PTY LTDP.O. BOX 332Braeside VIC 3195
FOOTLINK PTY LTD5/21 Johnston Court Dandenong VIC 3175
P 1300 535 645F 1300 515 685E [email protected]
LAB. POST CONTACT
In-toe Gait Plate
Out-toe Gait Plate
Morton’s Extension
L
L
L
R
R
R
daTES
COvER lENgTh
MOdIfICaTIONS & addITIONS
Name
Shoe Type
Sex Weight kg
age Shoe Size
NameClinicaddress
Phone
Order date / /
Return □48 hours (Rapid)3 Days (Standard)□□24 hours (Rapid) □Same day (Rapid)
MId layER
COvER TyPE
*all extensions have a Cambrelle base
□Shell length
□Sulcus length & Poron to web-space
Standard Web* Performance* □full length & Poron to end of shoe
□ □□ □□ □□ □
□vinyl □lunasoft □1.5 Spenco □3.0 Spenco
□Other
Cover Colour
□ 3.0 Blue □3.0 Red□1.5 Blue
□Other
left Right
Issue Date / /
US
heel Stabiliser heel aperture Met dome Met Pad 2-4
OTHER
RE-COVER & MODIFICATIONPRESCRIPTION FORM
P 1300 535 645F 1300 515 685E [email protected]
PRACTITIONER
PATIENT
□1.5 Red
Full Length EVA □Full Length EVA to the end of shoe
Cover Trim