Mid Atlantic Corporate Center           1595 Imperial Way - Suite 103                 W. Deptford, NJ 08066 USA

Tel: 800-336-6302  Fax: 856-848-7944   International Tel: 01-856-848-6226

Date send to lab _____________________

PRESCRIPTION  FORM

Please complete for faster service

PATIENT INFORMATION

Name:_____________________________________________ Age:_________  Sex:________  Wt:_______Shoe Size:_______ Shoe Type:______________ Occupation:__________________  Activity Level:_______________________________________ Symptoms/Diagnosis:__________________________________  __________________________________________________

ACCOUNT INFORMATION

Practice Name/Practitioner:_____________________________ Account No.______________                                                        Address:__________________________________________  City:________________ State:______ Zip Code:__________ Phone Number:____________________________________

SUPER SAVER FORM

Step 1.      SELECT POLYPRO SHELL THICKNESS

  • 1/8" Polypropylene Shell - For patients weighing up to 175 pounds
  • 5/32" Polypropylene Shell - For patients weighing up to 250 pounds

Step 2.   SELECT RIGID EVA POSTING REQUIREMENTS

  • Rearfoot  INTRINSIC - Number of degrees  _____°    ___Varus     ___Valgus    ____No Degrees
  • Rearfoot EXTRINSIC - Number of degrees  _____°    ___Varus    ____Valgus    ____No Degrees

Step 3.    SELECT 1/8" EVA TOP COVER

  • Met Heads Length - Size of  Shell
  • Sulcus Length - 3/4 of Full Length approx.
  • Full Length - Shoe Size _______    Male__   Female__

I am Sending / Including :

  • Casts                                         Return?     Yes     No  
  • Bio-Foams
  • Data Disk
  • Template / Inserts for Sizing
  • Shoes   (1)   (2)

Notes :_____________________________________________________________________________________________

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Physician's Signature _________________________________________

 

FOR LAB USE ONLY

Log# ___________________

Return Cast ___    Shoes____   (1)  (2)