Online Prescription — Footmed Orthotics

Clinic

Provider e-mail

Weight

Relevant History/Findings

RCSP Foot Arch Height LEFT

RCSP Foot Arch Height RIGHT

Orthotic Style

Shell Thickness (custom) @ 0.1 increments

Posting Information LEFT

Devices will be corrected to perpendicular unless specified

Posting Information RIGHT

Devices will be corrected to perpendicular unless specified

Medial Heel Skive LEFT

@15 degrees

Medial Heel Skive RIGHT

@ 15 degrees

Elevation

Heel Height

Shell Width

Topcover Selection

Topcover Length

If no selection default will be full length

Heel Raise LEFT

Heel Raise RIGHT

Pad Size/Placement Instructions

Unless defined, lab defaults will be used

Additional Instructions/Requests

Cast delivery/submission

Custom Orthotic Prescription Form