Test FormOrthotech Laboratory

FORM TEST PAGE

Name:
Phone:
Email:
Clinic:
Address:
Name:
Date(auto)
Age
Size (US)
Required Date:
L
R
Rear Foot:
Fore Foot:
[DESIGN]

Mid Foot

Mood Root
Mood Root
Mood Root

Rear Foot

Inverted
HS Wedge

Combination

HS Wedge
Mid Inverted
Other
[MILA FILL]
Minimal
Medium
Maximal
Arch Height (mm)
L
R
Help Exp
Heel Width
Cuboid Notch (mm)
Medial Kirby Skive (mm)
Lateral Kirby Skive (mm)
Calc.Inc.Angle
Cast Elevation (if not 4mm)
Lat Cast Grind
PFA (mm)
No Fill 2-4
Medial Flare
Lateral Flare
Medial Wrap
Navicular Wrap
UCBL
Grind
Auditions
L
R
Rearfoot Post
Poron/Eva & Density:
Heel Lift (mm)
Heel Cup Depth (mm)
FHSA
MET DOME
Size:
Placement:
1st MPJ Cutout
1st RAY Cutout
Mortons Extension
Sheel/Poron/Eva:
Medial Flange
Lateral Flange
Arch Fills
Poron/Eva & Density:
Calcaneal Cutout (mm):
Out Toe Gait Plate
In Toe Gait Plate
Cover Length
Poron
Thickness/Colour:
Notes