SHOES | CUSTOM | FIND SHOE SIZE | SUPPORT | ORDERS
CUSTOM INSERTS ORDER FORM

Custom Shoes    Custom Inserts
Notes: All custom shoe casts must be closed-toe to ensure best fit.

Ordered By:
P. O. Number:
Phone:
Email:
ShipVia:
Ship To:
Address:
City:
State:     Zip:
Country:
Patient Information:   Name: Sex: Male Female
Diagnosis:Diabetes   Neuropathy
Heel Spur:L R        Ulcer: L R  
Callous:L R  
Charcot: L R   hide box
Foot Measurements: hide
MeasurementsLeftRight
Ball Width:
Foot Length:
Toe Height:
Foot Drawing
Circumf.LeftRight
Ball
Instep
Heel
Shoe Specifications: No shoes   Order regular shoes   Order custom shoes  
Style:(L)
(R)
Size:(L)
(R)
Color:
View styles
Shoe Modifications: hide
Insert Specifications: Diabetic Functional     Qty: (L)   (R)
Layers: Tri-lam   Bi-Lam
Base: EVA Cork Thermocork PPT
Density: Soft   Medium   Firm
Heel Cup: Flat Medium Deep
Met Pad: L R    
Toe Fillers: L R         hide box
Order Notes:
Attachments:
(Frequently Asked Questions)
To attach multiple files, please wait until the name of the current file appears below, then proceed to the next file.
    Log into your account before submitting files/order.
    v1.5