FUNCTIONAL ORTHOTIC ORDER FORM

Store ID#:

Required field

Clinician: Phone: Date:

PATIENT NAME First M.I. Last

Shoe Size Width Template #

Base Layer

Left Only Right Only

Top Layer

Middle Layer (optional)

3/4 Length

Male Female

SulcusFull Length

Standard (Decreased 1/8” from patient’s cast)

Total Contact (Made to patient’s cast)

Increased 1/8”from patient’s cast Other

CASTING MODIFICATION

ADVANCED OPTIONS

Quantity Ordered

GENDER

ARCH HEIGHT

TOP LAYER

TRIM LINES

HEEL POSTINGS

Put “1” for neutral post

Medial Wedge

Left Rightmm Medial Wedge mm

Lateral Wedge mm Lateral Wedge

Heel Lift mm Heel Lift

mm

mm

BASE LAYER

MID LAYER

1.5mm Spenco 2mm Poron

3mm Spenco 3mm Poron

Semi-RigidRigid

1/8” 1/8” 1/16”

Polypropylene CoPoly Graphite

3/16”

Flexible 1/16”

3/16”

1-877-229-9652 Arch Fitters 1625 SE Hogan Rd, Suite G Gresham, OR 97080

Special Instructions:

Contact E-mail:Additional charges may apply1

21

1

1

Pairs 2

High Medial Wall

High Lateral Wall

3 3

3Default 2

Both Left Right

NORMAL

LOW

DRESS

Both RightLeft

DEEP

UCBL

1

PLASTAZOTE

25 DM

35 DM

20 DM

15 DM

20 DM

1mm Black 1mm Brown

1.5mm25 DM

2mm Lt Blue Pu�

2mm Pink 3mm Pink

3mm Pink Pu�

3mm Lt Blue Pu�

3mm 4.5mm

3mm Blue

2mm Camo Swirl

2mm Pink Pu�

2mm Pink Swirl

2mm Blue Swirl

2mm Black Solid

2mm Blue

SPENCO (DUAL CLOTH)

NAUGAHYDE

35 DM

3mm Camo Swirl

3mm Pink Swirl

3mm Blue Swirl

3mm Black Solid

MICROCELL PUFF

MET-PADLeftBoth Right

Medium

Medium

Bar

Wide

Wide

Bar

Medium

Medium

Bar

Wide

Wide

Bar

Medium

Medium

Bar

Wide

Wide

Bar

STANDARD

AGGRESSIVE

HEEL CUP HEIGHT

1625 SE Hogan Rd Suite G, Gresham, OR 97080 Phone: 877-229-9652 Fax: 503-489-0706

www.archfitters.com

*Additional charges may apply, see your pricing plan for details or call 877-229-9652.

ARCH FITTERS TEMPLATE DIMENSIONS

Template Size Length Heel BOF Template Size Length Heel BOF1 (wms 5 mens 4) 9.16 2.186 3.231 13 (wms 5 mens 4) 9.16 2.268 3.3512 (wms 6 mens 5) 9.501 2.245 3.329 14 (wms 6 mens 5) 9.501 2.327 3.4493 (wms 7 mens 6) 9.842 2.304 3.427 15 (wms 7 mens 6) 9.842 2.386 3.5474 (wms 8 mens 7) 10.183 2.363 3.525 16 (wms 8 mens 7) 10.183 2.445 3.6455 (wms 9 mens 8) 10.524 2.422 3.623 17 (wms 9 mens 8) 10.524 2.504 3.7436 (wms 10 mens 9) 10.865 2.481 3.721 18 (wms 10 mens 9) 10.865 2.563 3.8417 (wms 11 mens 10) 11.206 2.54 3.819 19 (wms 11 mens 10) 11.206 2.622 8 (wms 12 mens 11) 11.547 2.599 3.917 20 (wms 12 mens 11) 11.547 2.6819 (wms 13 mens 12) 11.888 2.658 4.015 21 (wms 13 mens 12) 11.888 2.74 10 (mens 13) 12.229 2.717 4.113 22 (mens 13) 12.229 2.799 4.23311 (mens 14) 12.57 2.776 4.211 23 (mens 14) 12.57 2.858 4.33112 (mens 15) 12.911 2.835 4.309 24 (mens 15) 12.911 2.917 4.42949 (mens 16) 13.252 2.894 4.407 52 (mens 16) 13.252 2.976 4.52750 (mens 17) 13.593 2.953 4.505 53 (mens 17) 13.593 3.035 4.62551 (mens 18) 13.934 3.012 4.603 54 (mens 18) 13.934 3.094 4.723

X-WIDE: WOMENS 2E, MENS 4E

MEDIUM: WOMENS B, MENS D WIDE: WOMENS D, MENS 2E

XX-WIDE: WOMENS 4-E-6E, MENS 6E-8E

Template Size Length Heel BOF Template Size Length Heel BOF25 (wms 5 mens 4) 9.16 2.35 3.471 37 (wms 5 mens 4) 9.16 2.432 3.59126 (wms 6 mens 5) 9.501 2.409 3.569 38 (wms 6 mens 5) 9.501 2.491 3.68927 (wms 7 mens 6) 9.842 2.468 3.667 39 (wms 7 mens 6) 9.842 2.55 3.78728 (wms 8 mens 7) 10.183 2.527 3.765 40 (wms 8 mens 7) 10.183 2.609 3.88529 (wms 9 mens 8) 10.524 2.586 3.863 41 (wms 9 mens 8) 10.524 2.668 3.98330 (wms 10 mens 9) 10.865 2.645 3.961 42 (wms 10 mens 9) 10.865 2.727 4.08131 (wms 11 mens 10) 11.206 2.704 4.059 43 (wms 11 mens 10) 11.206 2.786 4.17932 (wms 12 mens 11) 11.547 2.763 4.157 44 (wms 12 mens 11) 11.547 2.845 4.27733 (wms 13 mens 12) 11.888 2.822 4.255 45 (wms 13 mens 12) 11.888 2.904 4.37534 (mens 13) 12.229 2.881 4.353 46 (mens 13) 12.229 2.963 4.47335 (mens 14) 12.57 2.94 4.451 47 (mens 14) 12.57 3.022 4.57136 (mens 15) 12.911 2.999 4.549 48 (mens 15) 12.911 3.081 4.66955 (mens 16) 13.252 3.058 4.647 58 (mens 16) 13.252 3.14 4.57156 (mens 17) 13.593 3.117 4.745 59 (mens 17) 13.593 3.199 4.66957 (mens 18) 13.934 3.176 4.843 60 (mens 18) 13.934 3.258 4.767

TODDLER

Template Size Length Heel BOF

Template Size Length Heel BOF

61.255.170.5)Toddler4( 1622.26.114.5)Toddler5( 2623.256.137.5)Toddler6( 3693.27.160.6)Toddler7( 465.257.14.6)Toddler8( 5675.28.127.6)Toddler9( 66

YOUTH

95.258.160.7)Toddler 01( 7676.29.14.7)Toddler 11( 8677.259.147.7)Toddler 21( 9638.2270.8)Toddler 31( 0729.250.24.8)htuoY 1( 1710.31.237.8)htuoY 2( 2780.351.260.9)htuoY 3( 37

4.0373.939

4.135