CUSTOM DIABETIC INSERTS ORDER FORM
ORDER INFORMATION :
Company Name : ______________________________________________________________________________________
Account #: ___________________________________________ PO #: __________________________________________ Contact Name : ________________________________________________________________________________________ Phone : ___________________________________ Email : ____________________________________________________ Ship-To Name : ______________________________________________________________________________________ Ship-To Address : ____________________________________________________________________________________ City : ___________________________________________ State : _________________ Zip : __________________________ Patient Name : ______________________________________________________________________________________
TO ORDER :
Place this form into impression box and ship with FedEx Prepaid label to : OrthoFeet , 335 Chestnut Street , Norwood , NJ 07648
Need shipping labels ? Go to orthofeet . shoes / labels to print a free shipping label .
STYLE # |
SHOE NAME |
SIZE |
WIDTH |
|
|
|
N , M , W , XW , XXW |
Please provide patient shoe information ( size and width ) if NOT ordering shoes with custom inserts .
|
CUSTOM INSERTS ( A5514 )
# OF PAIRS TYPE
|
ACCOMMODATIONS * Plantar View |
3 2 1 ____ |
Bilam : 3 / 16 ” EVA base layer , 1 / 8 ” OrthoSoft pink top |
Right
SUBMET
Left
|
|
3 2 1 ____
Will make 3 pairs if not specified .
TOE FILLER Left
Trilam : 3 / 16 ” EVA base , 1 / 8 ” Recoil layer , 1 / 18 ” OrthoSoft
Right
|
5
4
|
3 |
2 |
1 |
1 |
|
2 3 4 5
1 2 3 4 5 1 2 3 4 5 1 2 3 4 5
METPAD FOR PATIENTS WITH PARTIAL FOOT AMPUTATIONS TYPE OTHER QTY .
1 Left Partial Foot Filler ( L5000 ) 3 Right Custom Inserts ( A5514 ) 1 Right Partial Foot Filler ( L5000 ) 3 Left Custom Inserts ( A5514 )
Include foot tracing for partial foot filler .
ARCH HEIGHT High Med Low Default to Med
Accommodations MUST be indicated on form and in foam .
Feet Asymmetrical Make inserts match casts
Ship 1 case ( 12 Boxes ) of OrthoFeet 12 ” Impression Foam |
Other Qty . ___________ |
Ship 1 case ( 10 Boxes ) of OrthoFeet 14 ” Impression Foam
Other Qty . ___________ Email customs @ orthofeet . com | Phone 800.524.2845 | Fax 201.767.6748
335 Chestnut Street , Norwood , NJ 07648 CDI202310