PLACE ACCOUNT LABEL HEREPREMIER

PATIENT INFORMATION

Name

Shoe Size* Male Female

Date of Birth Weight

Shoes / Insoles Enclosed

Previous Rx# Date

SHIPPING INFORMATION IF SHIP TO PATIENT OR LOCATION OTHER THAN BAR CODE.

Street Address

City State & ZIP

Physician’s Signature

P.O. Number ORDER OPTIONS ADDITIONAL CHARGES WILL APPLY

Return Positive MoldsSOLO BoxesUS Mail Labels ________UPS Labels __________

RUSH upgrade: Next Business Day3 Business DaysOVERNIGHT SHIPPINGRUSH CHARGES DO NOT INCLUDE OVERNIGHT SHIPPINGMail-to-Patient INCLUDE SHIPPING ADDRESS (TO THE RIGHT)

FUNCTIONALPolypropylene shell by patient weight, extrinsic rearfoot post, standard heel depth, and orthotic width, Leatherette top cover to mets Cobra Shadow

Cork (Shell to toes, standard heel depth, molded Plastizote top cover to toes)

Heel PadL R

Horseshoe PadL R

Met PadL RSoft Firm

1/16"1/8"

3/16"

Met BarL RSoft Firm

1/16"1/8"

3/16"

Scaphoid PadL RSoft Firm

1/16"1/8"

3/16"

Lateral FlangeL R

Lateral ClipL R

Heel Depth

X-Deep, 18 mmDeep, 15 mmStandard, 12 mmLow, 8 mm

Shell WidthWideStandardNarrowHourglass

POSTING ForefootNo Post

IntrinsicExtrinsic

Tip PostsTo Casts

L __________ varus / valgus

R __________ varus / valgus

L _________________ varus / valgus

Runner’s Wedge R _________________ varus / valgus

RearfootNo Post

IntrinsicExtrinsic To Vertical(low profile)

L __________ varus / valgus

R __________ varus / valgus

Heel Lift Korex Crepe In Increments L _________" inches

R _________" inches

Top Cover LengthTo ToesTo SulcusTo MetsNo Cover

TOP COVER (choose 1)Leatherette, Vintage BurgundyLeatherette, Cherry RedLeatherette, Saddle BrownLeatherette, Onyx BlackLeatherette, Smoke Gray

Neoprene 1/16”Neoprene 1/8”PlastizoteEVA 1/16"EVA 1/8"Leather

1st Met Cut Out

L R

K Wedge

L R

Morton’s Ext. in shell

L R

Turf Toe

L R

Shell RigidityFlexibleSemi-Flexible

Semi-RigidRigid

OR Indicate Specific Polyproplene Thickness

STANDARD DRESSPolypropylene shell by patient weight, intrinsic rearfoot post, x-low heel depth and hourglass width, Leatherette top cover to mets

EVA ShellLeather Shell (Shell to mets, leather top cover to toes)Firm Plastizote Shell

X-Low, 5 mm

Medial Flange/PlatformLowMediumHighMini Platform

L R

Standard Platform

ACCOMMODATIVE

Notes

PAIHO® Bamboo 1/8” Private Label Top Cover

Dri-Brelle®UPGRADED TOP COVERE

Left RightTOE FILLERD

Standard Reduced BulkARCH REINFORCEMENTB

L RINTRINSIC HEEL PAD

OPTIONAL UPGRADES ADDITIONAL CHARGES APPLY. SEE PRICE LIST.

UPGRADED PLATEA

RX-ARX-BRX-C

Performance Rx Engineered Nylon

2 mm2.5 mm2.9 mm

Carboplast II Graphite

1.25 mm1.4 mm

DBX Graphite

ADDITIONAL ACCOMMODATIONSC PaddingSoftFirm

1/16" 1/8"

3/16"L R

Cut Out1/16" 1/8” 3/16"

L R

1/16" 1/8” 3/16"Channel L R

LEFT RIGHT

1 23

45

123

54

Lab Standards apply when order form is incomplete.*If shoe size is not supplied, any repair charges needed will be applied

Mets Sulcus Toes Distal to Sulcus

Distal to Toes

Balance Pad

SoftFirm

1/16" 1/8"3/16"

Dancer’s Pad

SoftFirm

1/16” 1/8”3/16”

Morton’s Ext Pad

SoftFirm

1/16”

1/8”3/16”

L RL R L R

415 South Laurel Street, Kutztown, PA 19530 | 800-765-6522 | Fax 610-683-6427 | www.sololabs.comUPDATED 8/23/19

Barcodes Order Forms

Padded Flange

L R