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Shoe Work Order Form

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PATIENT INFORMATION:
* = Required
Patient's Name:*		Patient ID#
Today's Date:		Due Date:
Account #		P.O. #
Facility: *		Practitioner:*
Bill to:*
Ship to:*
	Ground 2 Day Next Day
Total Number of Shoes:		Shoe Size:	Left Right

SHOE WORK ORDER DESCRIPTION:

1. Lift

N/A

Select One:
Left
Right
Bilateral

Select One:
Add lift to bottom
Cut sole apart

Heel Lift:
Sole Lift:
Lift Removal:

Topy
Vibram
H.D.

2. Rocker

N/A

Select One: Left Right Bilateral Select One: Heel & Toe Forefoot Rocker Removal	Mild (Add up to 1/4 crepe then grind rocker):
	Standard (Add up to 3/8 crepe then grind rocker):
	Severe (Add up to 1/2 crepe then grind rocker):

3. Flare

N/A

Left Right Bilateral	Heel Only Sole Only Heel & Sole	Medial Lateral
Width:		Flare Removal

4. Wedge

N/A

Left Right Bilateral	Heel Only Sole Only Heel & Sole	Medial Lateral
Height:	Wedge Removal:

5. Shank

N/A

Left Right	Bilateral Extend	Short Removal	Spring Steel:		1.25:
Left Right	Bilateral Extend	Short Removal	Carbon:		2:

6. Velcro Closure

N/A

Left
Right
Bilateral

Loop Medial
Loop Lateral

Speed Lace Install:
Left
Right
Bilateral

7. Sole & Heel

N/A

Re Sole:
Left
Right
Bilateral

Re Heel:
Left
Right
Bilateral

Removal:

8. Gussets

N/A

Left Right Bilateral	Medial:
Left Right Bilateral	Lateral:

9. Shoe Tongue Modification

N/A

Width: Length:

ADDITIONAL INSTRUCTIONS:

Write the characters fromn the following security image:

Change Image

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