APIS CUSTOM ORDER FORM
Order Type: Custom Shoes    Diabetic Inserts    Functional Orthotics
ORDER INFORMATION
Contact:
PO No.:
Phone:
Email:
ShipVia:
Ship To:
Address:
City:
State:     Zip:
Country: Update Profile
PATIENT INFORMATION
Name:
Sex: Male Female   
Weight:
Diagnosis: Diabetes
  Neuropathy
Ulcer: L R  
Callous: L R  
Charcot: L R
Heel Spur: L R  
Metatarsalgia: L R
Plantar Fasciitis: L R
Hammer Toes: L R
FOOT MEASUREMENTS
Foot Len.: L   R
Ball Width: L   R
Toe Height: L   R
Foot Drawing
Ball Circ. L   R
Instep Circ. L   R
Heel Circ. L   R
SHOE SPECIFICATIONS
Order Shoes:
Yes No   Modify Soles: Yes No
Shoe Style: L
  R
Shoe Size: L
  R
Shoe Color:
  View styles
Extra toebox ht.: L R
Extra width: L R
Toe ext.: L R
Plastizote Lining: L R
Padded Tongue: L R
Padded Collar: L R
Composite Toe-box: L R
Reinf. Heel Counter: L R
Heavy Duty Sole: L R
Sole Density: Rigid Semi-rigid
SOLE MODIFICATIONS
Rocker: L R
Med. wedge: L R
Lat. wedge: L R
Med. flare: L R
Lat. flare: L R
Heel lift: L R
Bevel Heel: L R
SACH Heel: L R
Lift inside: L R
Steel Shank (L): 3/4 Length Full Length Leave Sole Off
Steel Shank (R): 3/4 Length Full Length Leave Sole Off
DIABETIC INSERTS
Insert Qty: L   R  
Std. Material: Tri-lam (Plastazote + PPT + EVA)
Top Cover: Plastazote Spenco Leather PPT
Base: EVA Thermocork Cork
Base Density: Soft   Medium   Firm
Heel Cup: Flat Medium Deep
Met Pad: L R
Arch Pad: L R
Toe Filler: L: 1 2 3 4 5
(Mark digits) R: 1 2 3 4 5
FUNCTIONAL ORTHOTICS
Modification Methods:
Modified Root (STD)
Inverted
Medial Skive mm
Other
Rear Foot Correction:
Left Foot:   °
Inverted Everted
Right Foot: °
Inverted Everted
Extra Talo-Navic Control
Extra Mid Arch Control
Extra Heel Expension
Plantar Fascia Groove
Extra Plaster First Ray
Cuboid Notch S M L

Shell Materials:
4.5 mm Polypro
3 mm Polypro
Carbon Fibre
EVA - Soft
EVA - Medium
EVA - Firm
Lab Discretion
Shell Selection:
Morton's Ext.
L:mm    R:mm
Apertured S M L
First Ray Cut Out
Low Bulk Grind Cobra
Meidal Flare
Medial Flange
Lateral Flange
Posting:
Rear Foot EVA posts
Heel Raise: L:mm R:mm
No Heel Plate
EVA Arch Fill Soft Reg
Forefoot EVA Posts
L: ° Inversion Eversion
R: ° Inversion Eversion
 

Met Pads:
Small
Medium
Large
Extra Large
Other
Padding:
ShellForefoot
None
1.5mm PPT
3.0 PPT
Cover Materials
Vinyl (STD.) Leather
Neoprene Other
Cover Length
Shell Web Full Length
NOTES & ATTACHMENTS
Order Notes:
Attachments:

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