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31 Smith Street
Moneymore
Magherafelt Co Derry
BT45 7PF
DATE:
PRACTITIONER:
PATIENT NAME:
CLINIC NAME:
PATIENT SHOE SIZE:
ADDRESS:
PATIENT WEIGHT:
CHIEF COMPLAINT:
EMAIL:
TELEPHONE:
PRESCRIPTION:
ORTHOTIC SHELL
LENGTH
MET PADS
REARFOOT POST
1ST MET CUTOUT
2MM
3/4
YES
LEFT
SULCUS
ALL MET PADS 10MM DISTAL
LO PROFILE AS STANDARD
LEFT
0
RIGHT
0
HIGH PROFILE
VARUS
20MM DISTAL
2MM REINFORCED
3MM
TOPCOVER
SOFT TOUCH
VINYL
LUNASOFT
1/16”
FULL LENGTH
ALL FULL LENGTH ORTHOTICS
COME WITH VINYL SANDWICH
AS STANDARD
RED
GREY MARBLE
BLACK
ETC
INTRIN. EXTRIN
RIGHT
CONTRAINDICATED
IF BIG TOE
A) DOESN’T BEND
B) IS PAINFUL TO BEND
VALGUS
MM
TO DRS MARK
FOOTWEAR
DRESS CASUAL SPORT BOOT FURTHER
CUSTOMISATION:
FOREFOOT PAD
FULL HEEL CUSH.
MORTONS EXT.
SCAPH PAD
LEFT
LEFT
LEFT
LEFT
RIGHT
RIGHT
RIGHT
RIGHT
SOFT
NORMAL
HARD
LOW
SUB MET ACCM.
SPUR PAD
LEFT
1
RIGHT
1
LEFT
2
2
3
3
EXTRA PADDING
4
4
(UNDER TOP COVER)
5
5
1/16”
RIGHT
SOCCER
FOREFOOT
POSTING EXTRIN.
LEFT
0
RIGHT
0
3/4
SULCUS
REV MORTON
SHOCK ABSORBER
LEFT
(UNDER HEEL)
RIGHT
LEFT
RED
SOFT
RIGHT
PINK
HARD
1/16”
LIME GREEN
1/8”
GREY MARBLE
1/8”
HEEL RAISE
LEFT
RIGHT
MM
MM
3 OPTIONS ( PLEASE TICK ONE
):ADDITIONAL INFORMATION:
CUSTOMISED ORTHOTICS
( 1FREE ALTERATION WITHIN THE FIRST 6WKS OF RECEIVING
ORIGINAL PRECRIPTION )
KIDS OUTGROWTH
( FIRST PAIR MUST BE RETURNED WITH SECOND ORDER FORM)
DOUBLE ORDER DISCOUNT
( SECOND PAIR HAVE TO BE ORDERED AT THE SAME TIME AS THE FIRST)
Warranty information. All our shells, excluding top covers, have a lifetime guarantee against breakage under normal usage.
Payment is taken at time of order. All practitioners should be aware that once a prescription has been submitted, any deviation from
the original order will incurr an additional charge.
feet
24 7
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