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About
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Custom Orthotic Script
Videos
Contact

Custom Orthotic Prescription

Practitioner Name

Practitioner Email

Order Date

Clinic Name

Is this a re-print order?

No Yes

Printing Location

In-clinic PodiaPrint Facility

Re-print Order number

Address

City

State

Postcode

Patient Details

Patient Name

Shoe Type

Length of Shoe Innersole

Innersole Width - Forefoot

Innersole Width- Heel

Device Design

Device Length

Finish

Density

Heel Cup

Arch Style

Arch Fill

Base Height

Rear Foot RIGHT Correction (degrees)

Direction

Rear Foot LEFT Correction (degrees)

Direction

Forefoot RIGHT Correction (degrees)

Direction

Forefoot LEFT Correction (degrees)

Direction

Modifications Left

Medial Skive Triplanar Skive Lateral Skive Cuboid Notch Fluent Cuboid Notch Sphere Extra Heel Expansion Heel Aperture 1st Ray Accommodation Gait Plate Plantar Fascial Accomodation Medial Flare Medial Flange Accommodation (Drops) - please place felt to site for scanning 1st MTPJ Cut-Out Heel Lift Long Heel Lift Short Mortons Extension 5th Ray Grind 5th Ray Brace

Modifications Right

Medial Skive Triplanar Skive Lateral Skive Cuboid Notch Fluent Cuboid Notch Sphere Extra Heel Expansion Heel Aperture 1st Ray Accommodation Gait Plate Plantar Fascial Accomodation Medial Flare Medial Flange Accommodation (Drops) - please place felt to site for scanning 1st MTPJ Cut-Out Heel Lift Long Heel Lift Short Mortons Extension 5th Ray Grind 5th Ray Brace

Additions Left

Cobra Pad Cobra Pad 1st Met Cut Out Lateral Extended Heel Spur U Shape Heel Pad D-Filler 2nd Met Cut Out D-Filler 1st Met Cut Out Medial Extended Pad Lateral Pronatory Pad Long Lateral Pronatory Pad Short Met Dome Standard Met Dome Wide Met Dome Narrow Plantar Metatarsal Pad 1 Plantar Metatarsal Pad 2-5 Plantar Metatarsal Pad 1-5 Plantar Metatarsal Pad 2-4 Medial Wedge Extension Pad Medial Skive Lateral Skive Lateral Wedge Extension Cluffy Wedge Toe Bar 2-5 Toe Bar 1-5 Met Bar 1-5 Met Bar 1-5-1 Met Bar 1-5-2 Met Bar 1-5-3

Additions Right

Cobra Pad Cobra Pad 1st Met Cut Out Lateral Extended Heel Spur U Shape Heel Pad D-Filler 2nd Met Cut Out D-Filler 1st Met Cut Out Medial Extended Pad Lateral Pronatory Pad Long Lateral Pronatory Pad Short Met Dome Standard Met Dome Wide Met Dome Narrow Plantar Metatarsal Pad 1 Plantar Metatarsal Pad 2-5 Plantar Metatarsal Pad 1-5 Plantar Metatarsal Pad 2-4 Medial Wedge Extension Pad Medial Skive Lateral Skive Lateral Wedge Extension Cluffy Wedge Toe Bar 2-5 Toe Bar 1-5 Met Bar 1-5 Met Bar 1-5-1 Met Bar 1-5-2 Met Bar 1-5-3

Additional Details & Submission Requirements

Does Your Prescription Require:

Deflections Changes to Density Additional Comments or Notes

Deflection Specifications (location, depth, width)

Density Specifications

Additional Comments or Notes

File Upload (upload any supporting files e.g. photos, APD files, pressure mapping)

Do you require a design preview? (typically only required for complex designs)

You confirm that email scans of both feet (e.g. Subject: John Smith Left) have been sent to scans@podiaprint.com.au?

Yes

You confirm that the prescription form has been checked and finalised?

Yes

You confirm that you are currently a registered podiatrist?

Yes

You confirm that you accept the terms and conditions?

Yes

Practitioner Name

Practitioner Email

Order Date

Clinic Name

Is this a re-print order?

No Yes

Printing Location

In-clinic PodiaPrint Facility

Re-print Order number

Address

City

State

Postcode

Patient Details

Patient Name

Shoe Type

Length of Shoe Innersole

Innersole Width - Forefoot

Innersole Width- Heel

Device Design

Device Length

Finish

Density

Heel Cup

Arch Style

Arch Fill

Base Height

Rear Foot RIGHT Correction (degrees)

Direction

Rear Foot LEFT Correction (degrees)

Direction

Forefoot RIGHT Correction (degrees)

Direction

Forefoot LEFT Correction (degrees)

Direction

Modifications Left

Medial Skive Triplanar Skive Lateral Skive Cuboid Notch Fluent Cuboid Notch Sphere Extra Heel Expansion Heel Aperture 1st Ray Accommodation Gait Plate Plantar Fascial Accomodation Medial Flare Medial Flange Accommodation (Drops) - please place felt to site for scanning 1st MTPJ Cut-Out Heel Lift Long Heel Lift Short Mortons Extension 5th Ray Grind 5th Ray Brace

Modifications Right

Medial Skive Triplanar Skive Lateral Skive Cuboid Notch Fluent Cuboid Notch Sphere Extra Heel Expansion Heel Aperture 1st Ray Accommodation Gait Plate Plantar Fascial Accomodation Medial Flare Medial Flange Accommodation (Drops) - please place felt to site for scanning 1st MTPJ Cut-Out Heel Lift Long Heel Lift Short Mortons Extension 5th Ray Grind 5th Ray Brace

Additions Left

Cobra Pad Cobra Pad 1st Met Cut Out Lateral Extended Heel Spur U Shape Heel Pad D-Filler 2nd Met Cut Out D-Filler 1st Met Cut Out Medial Extended Pad Lateral Pronatory Pad Long Lateral Pronatory Pad Short Met Dome Standard Met Dome Wide Met Dome Narrow Plantar Metatarsal Pad 1 Plantar Metatarsal Pad 2-5 Plantar Metatarsal Pad 1-5 Plantar Metatarsal Pad 2-4 Medial Wedge Extension Pad Medial Skive Lateral Skive Lateral Wedge Extension Cluffy Wedge Toe Bar 2-5 Toe Bar 1-5 Met Bar 1-5 Met Bar 1-5-1 Met Bar 1-5-2 Met Bar 1-5-3

Additions Right

Cobra Pad Cobra Pad 1st Met Cut Out Lateral Extended Heel Spur U Shape Heel Pad D-Filler 2nd Met Cut Out D-Filler 1st Met Cut Out Medial Extended Pad Lateral Pronatory Pad Long Lateral Pronatory Pad Short Met Dome Standard Met Dome Wide Met Dome Narrow Plantar Metatarsal Pad 1 Plantar Metatarsal Pad 2-5 Plantar Metatarsal Pad 1-5 Plantar Metatarsal Pad 2-4 Medial Wedge Extension Pad Medial Skive Lateral Skive Lateral Wedge Extension Cluffy Wedge Toe Bar 2-5 Toe Bar 1-5 Met Bar 1-5 Met Bar 1-5-1 Met Bar 1-5-2 Met Bar 1-5-3

Additional Details & Submission Requirements

Does Your Prescription Require:

Deflections Changes to Density Additional Comments or Notes

Deflection Specifications (location, depth, width)

Density Specifications

Additional Comments or Notes

File Upload (upload any supporting files e.g. photos, APD files, pressure mapping)

Do you require a design preview? (typically only required for complex designs)

You confirm that email scans of both feet (e.g. Subject: John Smith Left) have been sent to scans@podiaprint.com.au?

Yes

You confirm that the prescription form has been checked and finalised?

Yes

You confirm that you are currently a registered podiatrist?

Yes

You confirm that you accept the terms and conditions?

Yes

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