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PLACE ACCOUNT LABEL HEREPREMIER
PATIENT INFORMATION
Name
Shoe Size* Male Female
Date of Birth Weight
Shoes / Insoles Enclosed
Previous Rx# Date
SHIPPING INFORMATION IF SHIP TO PATIENT OR LOCATION OTHER THAN BAR CODE.
Street Address
City State & ZIP
Physician’s Signature
P.O. Number ORDER OPTIONS ADDITIONAL CHARGES WILL APPLY
Return Positive MoldsSOLO BoxesUS Mail Labels ________UPS Labels __________
RUSH upgrade: Next Business Day3 Business DaysOVERNIGHT SHIPPINGRUSH CHARGES DO NOT INCLUDE OVERNIGHT SHIPPINGMail-to-Patient INCLUDE SHIPPING ADDRESS (TO THE RIGHT)
FUNCTIONALPolypropylene shell by patient weight, extrinsic rearfoot post, standard heel depth, and orthotic width, Leatherette top cover to mets Cobra Shadow
Cork (Shell to toes, standard heel depth, molded Plastizote top cover to toes)
Heel PadL R
Horseshoe PadL R
Met PadL RSoft Firm
1/16"1/8"
3/16"
Met BarL RSoft Firm
1/16"1/8"
3/16"
Scaphoid PadL RSoft Firm
1/16"1/8"
3/16"
Lateral FlangeL R
Lateral ClipL R
Heel Depth
X-Deep, 18 mmDeep, 15 mmStandard, 12 mmLow, 8 mm
Shell WidthWideStandardNarrowHourglass
POSTING ForefootNo Post
IntrinsicExtrinsic
Tip PostsTo Casts
L __________ varus / valgus
R __________ varus / valgus
L _________________ varus / valgus
Runner’s Wedge R _________________ varus / valgus
RearfootNo Post
IntrinsicExtrinsic To Vertical(low profile)
L __________ varus / valgus
R __________ varus / valgus
Heel Lift Korex Crepe In Increments L _________" inches
R _________" inches
Top Cover LengthTo ToesTo SulcusTo MetsNo Cover
TOP COVER (choose 1)Leatherette, Vintage BurgundyLeatherette, Cherry RedLeatherette, Saddle BrownLeatherette, Onyx BlackLeatherette, Smoke Gray
Neoprene 1/16”Neoprene 1/8”PlastizoteEVA 1/16"EVA 1/8"Leather
1st Met Cut Out
L R
K Wedge
L R
Morton’s Ext. in shell
L R
Turf Toe
L R
Shell RigidityFlexibleSemi-Flexible
Semi-RigidRigid
OR Indicate Specific Polyproplene Thickness
STANDARD DRESSPolypropylene shell by patient weight, intrinsic rearfoot post, x-low heel depth and hourglass width, Leatherette top cover to mets
EVA ShellLeather Shell (Shell to mets, leather top cover to toes)Firm Plastizote Shell
X-Low, 5 mm
Medial Flange/PlatformLowMediumHighMini Platform
L R
Standard Platform
ACCOMMODATIVE
Notes
PAIHO® Bamboo 1/8” Private Label Top Cover
Dri-Brelle®UPGRADED TOP COVERE
Left RightTOE FILLERD
Standard Reduced BulkARCH REINFORCEMENTB
L RINTRINSIC HEEL PAD
OPTIONAL UPGRADES ADDITIONAL CHARGES APPLY. SEE PRICE LIST.
UPGRADED PLATEA
RX-ARX-BRX-C
Performance Rx Engineered Nylon
2 mm2.5 mm2.9 mm
Carboplast II Graphite
1.25 mm1.4 mm
DBX Graphite
ADDITIONAL ACCOMMODATIONSC PaddingSoftFirm
1/16" 1/8"
3/16"L R
Cut Out1/16" 1/8” 3/16"
L R
1/16" 1/8” 3/16"Channel L R
LEFT RIGHT
1 23
45
123
54
Lab Standards apply when order form is incomplete.*If shoe size is not supplied, any repair charges needed will be applied
Mets Sulcus Toes Distal to Sulcus
Distal to Toes
Balance Pad
SoftFirm
1/16" 1/8"3/16"
Dancer’s Pad
SoftFirm
1/16” 1/8”3/16”
Morton’s Ext Pad
SoftFirm
1/16”
1/8”3/16”
L RL R L R
415 South Laurel Street, Kutztown, PA 19530 | 800-765-6522 | Fax 610-683-6427 | www.sololabs.comUPDATED 8/23/19
Barcodes Order Forms
Padded Flange
L R