New FormOrthotech Laboratory

Custom Orthotics Form

Podiatrist
Name:
Phone:
Email:
Clinic:
Address:

Patient
Name:
Date(auto)
MaleFemale
Age:
Size (US):

Return Required
StandardExpress
Required Date:

Cast Modification - (Info)
L
R

Rear Foot:
vrvl
vrvl

Fore Foot:
vrvl
vrvl

[DESIGN]

Mid Foot

Mod Root
Yes
Yes

Mod Root

(Part 1st ray fill)

Yes
Yes

Mod Root

(Full 1st ray fill)

Yes
Yes


Rear Foot

Inverted

(Sus tail)

Yes
Yes

HS Wedge

(Sus tail)

Yes
Yes


Combination

HS Wedge

(Mid foot)

Yes
Yes

Mid Inverted

(talonavicular)

Yes
Yes

Other
Yes
Yes

[MILA FILL]

Minimal
Yes
Yes

Medium
Yes
Yes

Maximal
Yes
Yes

Arch Height (mm)

Cast/Shell Modification - (Info)
L
R

Heel Exp

Heel Width

Cuboid Notch (mm)

Kirby Skive (mm)

Calc.Inc.Angle

Cast Elevation (if not 4mm)

Lat Cast Grind

PFA (mm)

No Fill 2-4
Yes
Yes

Medial Flare
Yes
Yes

Lateral Flare
Yes
Yes

Medial Wrap
Yes
Yes

Navicular Wrap
Yes
Yes

Shell Material - (Info)
Yes POLLY (mm)
2344.55Other
Other:
Yes Composite (mm)
1.92.32.73Other
Other:
Shell Material Cont (Info)
Yes EVA
3/4 ShellFull Length 1pc
--------------
Very SoftSoftMedFirmVery Firm
Yes Dual Density (bottom layer)
Very SoftSoftMedFirmVery Firm
Yes Trilaminate (diabetic)
Yes Subortholene
2mm3mm4mm

Additions/Grind - (Info)
NormNarrowWideHookHook (full heel cover)Full Heel Court
Auditions
L
R
Rearfoot Post
Yes
Yes
Material & Density:
Heel Cup Depth
(std 12 mm)
Heel Lift (mm)
FHSA
Yes
Yes
* Foam Heel Spur Accommodation

Additions - (Info)
MET DOME
Yes
Yes
Size:
Placement:
1st MPJ Cutout
Yes
Yes
1st RAY Cutout
Yes
Yes
Mortons Extension
Yes
Yes
Shell/Poron/Eva:
Medial Flange
Yes
Yes
Lateral Flange
Yes
Yes
Arch Fills
Yes
Yes
Poron/Eva & Density:
Calcaneal Cutout (mm):
Out Toe Gait Plate
Yes
Yes
In Toe Gait Plate
Yes
Yes
(patient is out-toeing)
UCBL:
Yes
Yes

Cover Length - (Info) Clear
MetsSulcusF/L

Poron - (Info) Clear
1.6mm3.2mm6.4mm

ShellExtensionS&E

Covers - (Info) Clear
Personalised CoverVinylLeatherAMBNeopreneSuedeEVAPerf.EvaPS VliesPlastizoteNo Cover
RoughtSmooth
Thickness/Colour:

Notes

Upload Scans:
(yes/no)