• XCELA Functional continuous fiber reinforced composite 2.9mm          Circle One      flexible           Semi         Rigid
• POLYPROLINE  Functional white polypropylene              Circle one         1/8"       5/32"        3/16"     1/4"
• THE RELIEVER Functional heel spur device, arch fill, heel pocket and post
• PMBS Accommodative polypropylene 3/32" shell with Celon or SBR bottom fill
• EVA/POROZOTE Accommodative with 1/4" Porozote top layer         Circle One   Eva Shell     or   Rigid Plastizote Shell
• FLASHSTANCE   Women's Dress in 1/8" High Density Polyethylene
• ULTRALYT  Functional graphite/fiberglass resin composite 1.5 mm

• DURAFLEX  Functional acetal homopolymer                  Circle Plate thickness    2mm     3mm
• AEROBICS  Semi-functional/accommodative 1/4" rigid plastizote heat bonded to 3/32" polypropylene shell
• CORK&LEATHER  Accommodative Biocork Molded Shell Circle Shell length       Met Heads    or       Sulcus
• DIABETIC BALANCER  Low Bulk Accommodative 3/32" Polypro with Deep Heel Cup, medial flange and Foam Top Layer
• PERFORMERS  Prefabricated Acetal Shells                  Circle Plate Thickness    2mm    or    3mm
• HOT-SHOTS  Shiny Black Nylon  Molded by Injecction  (Prefabricated)  Shells only?    Yes      No

KIDSTUFF

• ROBERTS/WHITMAN Functional Control of Excessive Motion Subtalar & Midtarsal Joint Motion
• GAIT PLATE  Functional Control of In-Toe/Out-Toe deformity        Circle One    To Stop In-Toeing              or                To Stop Out-Toeing

HEEL STABILIZER

• TYPE A - For Moderate Pronation/Heel Eversion
• TYPE B - For Severe Pronation
• TYPE C - For Extreme Flaccid Foot
• TYPE D - To Stop In-Toeing
• TYPE E - To Stop Out-Toeing

REAR FOOT POST ( 3° Post-Lab Std)

 __Extrinsic   ___Intrinsic   ___No  Post

L______° Varus  ______°Motion              R______° Varus_______°Motion

• Omit Posting Plate for Decresed Bulk
• Grind Shell Paper Thin for Decresed Bulk
• Heel Rise  __Left ___Right  Height_____

FOREFOOT POST ( To Cast Intrinsic Lab Std)

 ___To Cast   ___Intrinsic   ___Extrinsic

 L______° Varus  ______°Valgus               R______° Varus_______°Valgus

• Omit Posting Plate for Decresed Bulk

SUPPLIES

• Prescription Forms
• Adjustment Forms
• Adjustmente Mailers
• Prepaid Postage Labels
• precisINSURANCE insurance forms

FOR LAB USE ONLY

Log# ___________________ Return Cast ___Shoes__ (1) (2)

• Widen Heel on Cast:  __1/16"    __1/8"    __1/4"    __3/8"    ________Other
• Lower Arch on Cast:    None (Type 1)    1/8"(Type 2)   1/4"(Type 3-Lab Std.)    3/8"(Type 4)     1/2"(Type 5)
• Raise Arch on Cast:  __1/16"    __1/8"     _______Other
• Medial Skive:  Right: _____mm.   Left: _____mm.       ___Both   ____mm.

• Narrow (Bisec 1st & 5th)   ___Regular (1st & 5 th - Lab Std.)    ___Wide (Full Foot Wide)
• Cut Out 1st Met head on Plate   ___Right    ___Left     ___Both
• Cut Out 1st Ray on Plate    ___Right   ___Left      ___Both
• Medial Flange    ___Slight   ___Regular (Lab Std.)   ___High        On     ___Right   ___Left    ___Both

• Flat (4mm)      __Shallow (8mm)     __Regular (12mm)     __Deep (16mm)       __Other _____mm.

• Foam Fill Under Arch of Orthotic       ___Full     ___Medium    ___Slight

• SBR (Lab Std.)
• Celon
• Plastizote
• Neoprene (Plain)
• Porozote

• 1/16"
• 1/8"
• 3/16"
• 1/4"
• Other_________

• Pad Extension Only
• Pad Heel to Toe
• Specify _______________ _____________________

• Suede Bottom Cover Shell only
• Suede Bottom Cover Full
• Poron Screen on Bottom Full