Sport Orthotics | Standard & Flexible Orthotics | Accomodative Orthotics | Graphite Standard & XT Sprint Orthotics |
TL-2100 Dress Orthotics | Pathology Specific Orthotics | Childrens Orthotics | Prescription Footwear | Rx Form 		 
Use this On-Line Rx Form or Print a Blank Version
Practitioner: Patient Last Name:
Phone: Patient First Name:
Bill To:
Date of Birth: Male Female
Ship To:
Weight: lbs Height: Shoe Size:
Rush Service: 1Day $40 2 Day $30 Please duplicate previous prescription #
  Ship to patient $12 Please fabricate two pair Send Boxes Rx Forms
PATHOLOGY SPECIFIC DEVICES - Direct Mill Process
Posterior Tibialis Dysfunction Metatarsalgia Plantar Fasciitis  
Hallux Limitus Pronation Control Achilles Tendonitis Pediatric Flat Foot
FUNCTIONAL/ACCOMMODATIVE/DRESS DEVICES -Vacuum Press Process
Sport    
Impact Sport    
Standard    
Flexible    
Polynyolene: 3mm Skintone 2.5mm White Transparent
Mold: Poron Puff
Tri-Density    
Bio-Cork    
EVA Device: To Mets To Toes
TL 2100 Dress: With Heel Cups Without Heel Cups
TL 2100 Standard    
XT Sprint: Semi-Flexible Rigid
Other: (specify)
CHILDREN
Shaffer Plates Out-toe Gait PL (to correct in-toeing) UCBL
Roberts Whitman In-toe Gait PL (to correct out-toeing)  
FOOTWEAR
Orthotic Type: Functional Mold  
Style Ritzstick (size)
CAST DRESSING
Min (fill) Mod (fill) Max (fill) Medial Heel Skive LT mm RT mm
POSTING INSTRUCTIONS
Use lab discretion and post according to evaluation  
If you take measurements place values below:  
Subtalar LT Varus RT Varus
Forefoot LT Varus/ Valgus RT Varus/ Valgus
Tibial Varum ° °  
Post these values
Rearfoot EXTRINSIC INTRINSIC  
  LT Varus/ Valgus RT Varus/ Valgus
Forefoot EXTRINSIC INTRINSIC  
  LT Varus/ Valgus RT Varus/ Valgus
FF Post Corner Full Ext. To Sulcus 1/8" 2-5 bar with 1st met cutout
GRINDING INSTRUCTIONS
1st met cutout B/L LT RT
Narrow Grind Wide Cut    
High Medial Flange      
Deep Heel Cup 18mm 20mm 22mm
Heel Raise LT mm RT mm  
ADDITIONS/MODIFICATIONS
NEUROMA PAD (Interspace) MET PAD MORTONS EXTENSION HEEL PAD HEEL SPUR ACCOM .
LT RT Distally B/L LT RT B/L LT RT B/L LT RT
FHL ACCOM. B/L LT RT REVERSE MORTONS HEEL APERTURE BALANCE LESION ACCOM .
B/L LT RT PMP PAD B/L LT RT B/L LT RT LT RT
SHAFT PAD (1st ray) Distally ARCH PAD (dorsal) ARCH FILL (plantar) OTHER
B/L LT RT B/L LT RT B/L LT RT B/L LT RT
TOP COVERS
Vinyl Color:
Black Blue Green Grey Dk. Tan
No Covers To Mets      
To Sulcus To Toes      
Material:
1/16 Poron & Vinyl 1/8 Poron & Vinyl  
1/16 Puff 1/8 Puff 1/8 Spenco
Other/Extra Comments:
EXTENSIONS
To Sulcus To Toes
Material:

1/16 Poron & Vinyl

 1/8 Poron & Vinyl  
1/16 Puff 1/8 Puff 1/8 Spenco
Bottom Cover  
Other/Extra Comments:
 
Sport Orthotics | Standard & Flexible Orthotics | Accomodative Orthotics | Graphite Standard & XT Sprint Orthotics |
TL-2100 Dress Orthotics | Pathology Specific Orthotics | Childrens Orthotics | Prescription Footwear | Rx Form
 
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