APIS CUSTOM ORDER FORM(PDF)
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:
Update Profile
Order Information
Insert Type:
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:  
Lining:
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 ?)
Toe filler L: 1 2 3 4 5 TMA
digits R: 1 2 3 4 5 TMA
Sole Modifications
Rocker: L    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
LEFTRIGHT
Foot Length:
Ball Width:
Toe Height:
LEFTRIGHT
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: 
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