SHOES | CUSTOM | FIND SHOE SIZE | SUPPORT | ORDERS
CUSTOM INSERTS ORDER FORM
Custom Shoes    Custom Inserts
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 EVA-Cork PPT
Density: Soft   Medium   Firm
Heel Cup: Flat Medium Deep
Met Pad: L R    
Toe Fillers: L R         hide box
Order Notes:
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