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APIS CUSTOM ORDER FORM
(PDF)
Please select Order Type first.
Order Type:
Diabetic Inserts
Functional Orthotics
Custom Shoes
Notes: All custom shoe casts must be closed-toe to ensure best fit.
Account Information
Contact:
Company:
PO No.:
Phone:
Email:
Patient Name:
Gender:
Male
Female
Weight:
Shipping Information
Ship To:
Address:
City:
State:
Zip:
Country:
ShipVia:
Fedex Ground
Fedex 3rd Party
Fedex Collect
UPS Ground
UPS 3rd Party
UPS Collect
US Mail
US Priority Mail
Pick Up - CA
Pick UP - KY
Delivery - Mon
Delivery - Tue
Delivery - Wed
Delivery - Thur
Delivery - Fri
Update Profile
Order Information
Insert Type:
A5514
A5513
Functional
No Inserts
Insert Qty:
L
R
Toe-filler Qty:
L
R
Order Shoes:
Yes
No
Shoe Style:
L
R
Shoe Size:
L
R
Shoe Color:
Match length
Closure:
Lace
Velcro
Semi-Surgical
Surgical
Lining:
Leather
Mesh
Plastazote
Soft Cloth
Extra toebox ht.:
L
R
Orthotic Specifications
Std. Material:
Tri-lam (Plastazote+PPT+EVA)
Top Cover:
Plastazote
Spenco
Leather
Vinyl
Other:
Base:
EVA
Thermocork
Cork
Other:
Base Density:
Soft
Medium
Firm
Heel Cup:
Flat
Medium
Deep
Orthotic Modifications
Met Pad:
L
R
Met Bar:
L
R
Arch Pad:
L
R
Heel Pad:
L
R
Lat. Flange:
L
R
Med. Flange:
L
R
Offload:
L
R
(Mark on drawings
?
)
?
Click/tap to add offload;
Drag offload center to move;
Drag offload edge to resize;
Drag offload to lower corner to remove.
RIGHT LEFT
Toe filler L:
1
2
3
4
5
TMA
digits R:
1
2
3
4
5
TMA
Sole Modifications
Rocker:
Forefoot Rocker
Mild Rocker
Heel-To-Toe Rocker
Sever Rocker
Negative Rocker
Double Rocker
Rocker Bar
LOP Rocker
L
Forefoot Rocker
Mild Rocker
Heel-To-Toe Rocker
Sever Rocker
Negative Rocker
Double Rocker
Rocker Bar
LOP Rocker
R
3/4 Steel Shank:
L
R
Full Steel Shank:
L
R
Med. Buttress:
L
R
Lat. Buttress:
L
R
Bevel Heel:
L
R
SACH Heel:
L
R
Detach Sole:
L
R
Med. wedge:
L
R
Lat. wedge:
L
R
Med. flare:
L
R
Lat. flare:
L
R
Heel lift:
L
R
Heel-to-toe lift:
L
R
Build Lift:
Outsole
In shoe
Soling:
Light-weight
Heavy-duty
Rigid
Diagnosis
Diabetes
Neuropathy
Ulcer:
L
R
Charcot:
L
R
Heel Spur:
L
R
Metatarsalgia:
L
R
Amputated Toes:
L
R
Hammer Toes:
L
R
Foot Measurements
LEFT
RIGHT
Foot Length:
Ball Width:
Toe Height:
LEFT
RIGHT
Ball Circ.
Instep Circ.
Heel Circ.
Functional Specific Options
Shell:
3mm Polypro
4.5mm Polypro
Cork
Soft EVA
Medium EVA
Firm EVA
Carbon Fiber
Other:
Top Cover Len.:
Full
Sulcus
Shell
PPT Padding:
3mm
1.5mm
None
Cast Modifications
Lower Arch
L
R
Raise Arch
L
R
Fascia Groove
L
R
Medial Skive
L
R
Lateral Skive
L
R
Shell Modifications
UCBL Type
L
R
1st Ray Cutout
L
R
Heel Hole Punch
L
R
Arch Fill:
Soft
Reg.
Morton Ext.
L
R
Heel Posting
Neutral
No Posting
Varus Post:
°L
°R
Valgus Post:
°L
°R
Forefoot Posting
Neutral
No Posting
Varus Post:
°R
°L
Valgus Post:
°R
°L
Misc. Options
Extra Tongue Padding
Extra Collar Padding
Composite Toe Box
Reinforce Heel Counter
Order Notes:
Attachments:
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Acceptable 3D formats
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v2.0