Orthotric Lab Order
Dated In
Dated Out
Number
Patient Information
FIrst Name
Last Name
Weight LB
Gender
Shoe Size
Type Of Shoe
Ortotric Work Order
Biochemical Examinations FInding

Arch Height: No-Weight-Bearing

Arch Height: Weight-Bearing

1. Types of Orthotrics
2. Types of Underlay
Vinyl
Suede:
Microcell
3. Types of Top Covers
VINYL
SPORTS
MICROCELL
LEATHER
EVA PERFERATED
X STATIC
SUEDO
4. Types of Shell and Cushion
Deep Heel Cup
Length
Cusion
Types Of Shell
5. Modifications
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Heel Spur Pad
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Heel Cusion
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Met Pad
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Met Bar Pad
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Toe Crest
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Letral Clip
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Cubiod Pad
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High Medial Flang
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Heel Lift
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Reinforced Arch
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Rear Foot Posting
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Navicular Pac
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Scaphoid Pad
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Reverse Morton Extension
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Morton's Extension
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U Cut Out
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Extrensic Fore Foot Position
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Extrensic Rare Foot Position
6. Shell Modifications
Heel Center Pocket
1st Met Cut Out
1st Ray Cut Out
Fascia Grove
Kirby Skive
R -
mm
R -
mm
L -
mm
L -
mm
7. Additional Requests

Please note down additional requests here in pointers

8. Shoe Order
Notifications
View all Notifications