Functional Orthotics Order Form 10-2023

ACCOMMODATIONS L R ACCOMMODATIONS L R ˚
Metatarsal Pad Metatarsal Bar Heel Pad 1st Ray Shell Notch 5th Ray Shell Notch Dancer ’ s Pad Morton ’ s Extension Medial Flange Lateral Flange Arch Reinforcement
EXTRINSIC Rearfoot Medial Rearfoot Lateral Forefoot Medial Forefoot Lateral INTRINSIC Forefoot Medial Forefoot Lateral Left Right
STYLE # SHOE NAME SIZE
WIDTH N , M , W , XW , XXW