SOLO Labs Order Form

PREMIER

LIMITED

RELIEF

RICHIE BRACE

REPAIR

Please fix the following issues:

PREMIER

Patient First Name

Patient Last Name or ID *

DOB Mo

DOB Day

DOB Year

Weight (lbs) *

Shoe Size

Men's *

Women's *

Size *

Feet:

Left

Right

B/L

Shoes / Insoles Enclosed

PO Number

Previous Order #

Date

Shipping Options

Additional charges apply

Rush Upgrade:

OVERNIGHT SHIPPING NOT INCLUDED

Next Business Day

NOT AVAILABLE WITH 3D SHELLS

3 Business Days

NOT GUARANTEED WITH 3D SHELLS

Overnight Shipping

Mail To Patient

(Include ship to address)

UPS Labels

US Mail Labels

Ship to Account

Ship to Patient

Start typing to auto-complete address

Shipping Name *

Street Address *

City *

State *

Zip *

Physician's Name *

Device Type

Changing device type will reset all options to defaults

Functional

Standard

Dress

Standard

3D Shell

3D-A

3D-B

3D-C

3D-D

Flexible

Semi-Flexible

Semi-Rigid

Rigid

Accommodative

Cork

EVA

Shell Specifications

Shell Length

To Toes

To Sulcus

To Mets

Heel Depth

X-Deep 18mm

Deep 15mm

Std 12mm

Low 8mm

X-Low 5mm

Shell Width

Wide

Standard

Narrow

Hourglass

Arch Height (1/8" increments)

5 (no arch fill)

4 (Dress Std)

3 (Functional Std)

2

Arch Height

Shell Modifications

Medial Flange

Medial Flange

L

R

Low Medium High Mini Platform Std Platform

Lateral Flange

Lateral Flange

L

R

Lateral Clip

Lateral Clip

L

R

1st Met Cut Out

1st Met Cut Out

L

R

Morton's In Shell

Morton's Extension

L

R

K Wedge

K Wedge

L

R

3D Arch Reinforcement Bars

L

R

Forefoot Posting

Type

Intrinsic

Extrinsic

Tip

Runner's Wedge

L

To Cast

Varus

Valgus

Degrees

R

To Cast

Varus

Valgus

Degrees

Rearfoot Posting

Type

Intrinsic

Extrinsic

L

Vertical

Varus

Valgus

Degrees

R

Vertical

Varus

Valgus

Degrees

Heel Lift

L

R

1/16" 1/8" 3/16" 1/4"

Increments

Accommodations

Heel Pad

L

R

Horseshoe Pad

L

R

Scaphoid Pad

L

R

Met Bar

L

R

Met Pad

Met Pad

L

R

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

Topcover (to Mets)

Leatherette Burgundy

Leatherette Black

Leatherette Gray

P-Cell

Neoprene 1/16"

Neoprene 1/8"

Bamboo 1/8"

EVA 1/16" Black

EVA 1/16" Purple/Green Swirl

EVA 1/8" Black

EVA 1/8" Blue Speckle

Leather

No Cover

To Mets

To Mets

Modifications

Additional charges apply. See current price list.

A. Shell

Polypropylene

3/32"

1/8"

4mm

3/16"

Engineered Nylon

RX-A

RX-B

RX-C

Carboplast II Graphite

2.0 mm

2.5 mm

2.9 mm

DBX Graphite

1.25 mm

B. Arch Reinforcement & IHP

Arch Reinforcement

Standard

Reduced Bulk

Intrinsic Heel Pad

L

R

C. Additional Accommodations

Padding

1/16"

1/8"

3/16"

Heel to Mets

Heel to Sulcus

Heel to Toes

Distal to Sulcus

Distal to Toes

Padding Length

Padded Flange

L

R

Please clearly mark the foot (if scanning) or cast/foam for cut outs, channels, balance pads, dells, etc.

Cutout / Channel

L

R

Cutout Channel 1/16" 1/8" 3/16"

Balance Pad

Balance Pad

L

R

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

Morton's Extension Pad

Morton's Extension Pad

L

R

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

Dancer's Pad

Dancer Pad

L

R

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

D. Toe Filler

L

R

E. Topcover Length

To Sulcus

To Sulcus

To Toes

To Toes

Call to consult

Phone

Ext

No substitutions or modifications will be accepted.

3D Shell

3D-A

3D-B

3D-C

3D-D

Flexible

Semi-Flexible

Semi-Rigid

Rigid

Heel Depth

X-Deep

Deep

Standard

Shell Width

Standard

Narrow

Arch Height (1/8" increments)

5 (no arch fill)

4

3

2

Arch Height

Rearfoot Posting

Type

Intrinsic

Extrinsic

L

Vertical

Varus

Valgus

Degrees

R

Vertical

Varus

Valgus

Degrees

Heel Lift

L

R

1/8" 3/16" 1/4"

1st Met Cut Out

1st Met Cut Out

L

R

Met Pad

Met Pad

L

R

1/8"

Topcover

Leatherette to Mets

EVA 1/8" Black

To Mets

To Mets

Additional charges apply for longer lengths.

To Sulcus

To Sulcus

To Toes

To Toes

DEVICES

RELIEF A5514

Light-weight, total contact orthosis with an EVA base and molded P-Cell top cover.

1 Pair

2 Pairs

3 Pairs

3 Left

3 Right

1 Left with Toe Filler

1 Right with Toe Filler

RELIEF+ A5514

Light-weight, tri-density, total contact orthosis with an EVA base, Poron core and P-Cell top cover.

1 Pair

2 Pairs

3 Pairs

3 Left

3 Right

1 Left with Toe Filler

1 Right with Toe Filler

ACCOMMODATIONS

HEEL LIFT

L

R

1/16" 1/8" 3/16" 1/4"

Met Pad

Please mark the location of the Met Pads.

L

R

Met Bar

L

R

Cut Outs

Please clearly mark cut out location on the foot (if scanning) or cast/foam.

L

R

TOP COVERS

P-Cell

Notes

Call to consult

Phone

Ext

Activity Level

Non Ambulatory

Low/Transfer

Medium

High/Active

Diagnosis

Primary reason for the device

Clinical Observation

Ankle:

Normal/Flexible

Limited

Fixed/Fused

Forefoot:

Normal/Flexible

Limited

Fixed/Fused

Tibial Varum:

Adjust limb uprights for Tibial Varum

Special Instructions

STANDARD

Richie Brace Standard

Full Flexion Hinge

Restricted Hinge

Restricted Hinge Options

Medial Arch Suspender

Lateral Arch Suspender

Arch Hammock

DYNAMIC ASSIST

Richie Brace Dynamic Assist

SOLID AFO

Richie Brace Solid AFO

SOCCER

Richie Brace Soccer

Full Flexion Hinge

Restricted Hinge

LITTLE RICHIE

Richie Brace Little

Full Flexion Hinge

Restricted Hinge

Top Cover

EVA

Spenco

Plastazote/Poron

Top Cover Length

Met(Unavailable on Dynamic Assist)

Sulcus

Full

Add extra Poron

Heel Cup

10mm

14mm

18mm

35mm

Extrinsic Forefoot Post to Sulcus

Right:

Varus

Valgus

Degrees: °

Left:

Varus

Valgus

Degrees: °

Heel Skive

Right:

Medial: mm

Lateral: mm

Left:

Medial: mm

Lateral: mm

Modifications

Heel Lift: mm

Flange - Medial

Flange - Lateral

Fascial Groove (requires mark in cast)

Navicular (requires mark in cast and a medial flange or arch suspender)

Met Pad

Met Bar

Morton's Extension

Forefoot Accommodations:

1st

2nd

3rd

4th

5th

Other:

Previous Order

Order #

Date

Complete Refurbish

Repost to Current Specs

Forefoot Posting

Add

Change To

Type

Intrinsic

Extrinsic

Tip Posts

L

To Cast

Varus

Valgus

Degrees

R

To Cast

Varus

Valgus

Degrees

Runner's Wedge

L

R

K Wedge (1st Ray Cutout)

L

R

1st Met Cut Out

L

R

Rearfoot Posting

Add

Change To

Type

Intrinsic

Extrinsic

L

To Vertical

Varus

Valgus

Degrees

R

To Vertical

Varus

Valgus

Degrees

Heel Lift

L

R

1/16" 1/8" 3/16" 1/4"

Increments

Plate Modifications

Decrease Arch

L

R

1/8"

3/16"

1/4"

Increase Arch

L

R

1/8"

3/16"

1/4"

Decrease Heel Cup

L

R

1/8"

3/16"

1/4"

Narrow Device

L

R

1/8"

3/16"

1/4"

Shorten Device

L

R

1/8"

3/16"

1/4"

Notes

NOTE: LAB STANDARDS APPLY WHEN FORM IS INCOMPLETE.

Additions

Arch Reinforcement

Standard

Reduced Bulk

Heel Pad

L

R

Intrinsic

Padded

Horseshoe

Met Pad

L

R

1/16"

1/8"

3/16"

Met Bar

L

R

Scaphoid Pad

L

R

Padded Flange

L

R

Toe Filler

L

R

Padding

As Original

Change To

1/16"

1/8"

3/16"

Heel to Mets

Heel to Sulcus

Heel to Toes

Distal to Sulcus

Distal to Toes

Padding Length

Accommodations

As Original

Change To

Please clearly mark the location of cut outs, channels, balance pads, dells, etc.

Cut Out

Channel

L

R

1/16"

1/8"

3/16"

Balance Pad

L

R

1/16"

1/8"

3/16"

Dancer's Pad

L

R

1/16"

1/8"

3/16"

Morton's Ext Pad

L

R

1/16"

1/8"

3/16"

Top Covers

Leatherette Burgundy

Leatherette Black

Leatherette Gray

P-Cell

Neoprene 1/16"

Neoprene 1/8"

Bamboo 1/8"

EVA 1/16" Black

EVA 1/16" Purple/Green Swirl

EVA 1/8" Black

EVA 1/8" Blue Speckle

Leather

No Cover

Top Cover Length

To Mets

To Sulcus *

To Toes *

* Upgraded top cover charges apply

v1.0.15 2025-11-21