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APIS CUSTOM ORDER FORM
Please select Order Type first.
Order Type:
Custom Shoes
Diabetic Inserts
Functional Orthotics
Notes: All custom shoe casts must be closed-toe to ensure best fit.
ORDER INFORMATION
Contact:
PO No.:
Phone:
Email:
ShipVia:
Fedex Ground
Fedex Third Party
Fedex Collect
UPS Ground
UPS Third Party
UPS Collect
UPS Worldwide Saver Co
UPS Worldwide SaverFX Ground
US Mail Standard
US Priority Mail
Pick Up - CA
Pick UP - KY
Delivery - Monday
Delivery - Tuesday
Delivery - Wednesday
Delivery - Thursday
Delivery - Friday
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
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:
4.5
D
L
4.5
D
R
Shoe Color:
Black
Beige
Brown
Tan
Taupe
White
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:
Forefoot
Mild
Heel-To-Toe
Sever
Negative
Double
Rocker Bar
LOP Rocker
L
Forefoot
Mild
Heel-To-Toe
Sever
Negative
Double
Rocker Bar
LOP Rocker
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
A5513
A5514
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
Medium
Firm
Thermo Cork
Cork
Lab Discretion
Shell Selection:
Morton's Ext.
L:
mm R:
mm
Apertured
S
M
L
First Ray Cut Out
Low Bulk Grind
Cobra
Medial 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:
Shell
Forefoot
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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Frequently Asked Questions
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