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Hersco Ortho Labs: Orthotic Rx Form

*Fields marked in red are required

*Bill To: Company Name and Address
*Ship To: Company Name and Address
*Practitioner Name:
*Please contact me about this order via: Phone
Email

*Email Address:
*Phone Number:
P.O. number:
*Patient Name:
Age:
*Weight:
  Male Female
Shoe Size:
Shoe Type:
*Diagnosis and Special Instructions (if other shoe type, please describe):
Principal Use:
*Choose Orthotic Type:
If "Other," please describe:
  Pair Left Only Right Only
Shell Specifications (width):
Firmness:

Accomodations

Metatarsal pads:
Heel Spur:
Heel Cushion:
Morton's Extension:
1st Ray Cut Out:
*Top Cover Length:
Top Cover Material:
If you entered "Other" for Top Cover, please describe:
Heel Lift LEFT Only (how high):
Heel Raise RIGHT Only (how high):
Rear Foot Posting:
Degrees of Posting:
Forefoot Posting:
Degrees of Posting:
Please describe any additional posting instructions:
Drops/Reliefs- Please specify the precise location where relief is needed:
Toe Filler- Please describe in detail the area in need of the toe filler:
Other Special Instructions: