Device Type
Changing device type will reset all options to
defaults
Functional
Dress
3D Shell
Accommodative
Shell Specifications
Shell Length
Shell Width
Heel Depth
Arch Height (1/8" increments)
Shell Modifications
Medial Flange
L
R
Lateral Flange
Lateral Clip
1st Met Cut Out
Morton's In Shell
K Wedge
3D Arch Reinforcement Bars
Forefoot Posting
Type
L
Degrees
R
Degrees
Rearfoot Posting
Type
L
Degrees
R
Degrees
Heel Lift
L
R
Accommodations
Heel Pad
Horseshoe Pad
Scaphoid Pad
Met Bar
Met Pad
L
R
Topcover (to Mets)
Modifications
Additional charges apply. See current price list.
A. Shell
Polypropylene
Engineered Nylon
Carboplast II Graphite
DBX Graphite
B. Arch Reinforcement & IHP
Arch Reinforcement
Intrinsic Heel Pad
C. Additional Accommodations
Padding
Padded Flange
Please clearly mark the foot (if
scanning) or
cast/foam for cut outs, channels, balance pads, dells, etc.
Cutout / Channel
L
R
Balance Pad
L
R
Morton's Extension Pad
L
R
Dancer's Pad
L
R
D. Toe Filler
E. Topcover Length
Transcription fees apply
No substitutions or modifications will
be
accepted.
3D Shell
Heel Depth
Shell Width
Arch Height (1/8" increments)
Rearfoot Posting
Type
L
Degrees
R
Degrees
Heel Lift
L
R
1st Met Cut Out
Met Pad
L
R
Topcover
Additional charges apply
for
longer lengths.
Transcription fees apply
DEVICES
RELIEF A5514
Light-weight, total contact orthosis
with an
EVA base and molded P-Cell top cover.
RELIEF+
A5514
Light-weight, tri-density, total contact
orthosis with an EVA base, Poron core and P-Cell top cover.
ACCOMMODATIONS
HEEL LIFT
L
R
Met Pad
Met Bar
Cut Outs
Please clearly mark
cut
out location on the foot (if scanning) or
cast/foam.
TOP COVERS
Notes
Transcription fees apply
Activity Level
Diagnosis
Primary reason for the device
Clinical Observation
Ankle:
Forefoot:
Tibial Varum:
Special Instructions
Restricted Hinge Options
Top Cover
Top Cover Length
(Unavailable on Dynamic
Assist)
Heel Cup
Extrinsic Forefoot Post to Sulcus
Right:
°
Left:
°
Heel Skive
Right:
mm
mm
Left:
mm
mm
Modifications
mm
Forefoot Accommodations:
Transcription fees apply
Size
Left Qty
Right Qty
Size
Left Qty
Right Qty
Transcription fees apply
Activity Level
Diagnosis
Primary reason for device
Clinical Observation
Ankle:
Forefoot:
Special Instructions
Closure Type:
Laces
Color:
Height: (Measured from base heel to top of
collar)
Accommodations:
Closure Type:
Adjustable Hook and Loop Closure Strap
Color:
Tan
Height: (Measured from base heel to top of
collar)
9"
Accommodations:
Transcription fees apply
Activity Level
Diagnosis
Primary reason for the device
Clinical Observation
Ankle:
Forefoot:
Special Instructions
Closure Type:
Color:
Height:
(Measured from base heel to top of
collar)
Cast Modifications:
Ankle:
Forefoot:
Accommodations:
Circumference Measurements:
Closure Type:
Velcro with D-Ring
Lining:
Diabetic Plastazote
Height: (Measured from base heel to top of
collar)
Cast Modifications:
Transcription fees apply
Activity Level
Diagnosis
Primary reason for the device
Clinical Observation
Ankle:
Forefoot:
Special Instructions
ADVANCE TRADITIONAL
Only for Permanent Fixed Hinge:
Only for Permanent Fixed Hinge:
Top Cover:
Top Cover Length:
Forefoot Post:
Rearfoot Post:
Heel Skive:
Modifications:
requires mark in cast
requires mark in cast
and a medial flange or arch suspender
Forefoot Accommodations:
Transcription fees apply
Activity Level
Clinical Observation
Ankle:
Forefoot:
Diagnosis
Primary reason for the device
Plastic Color:
Measurements:
(Measured from base of heel to top)
Plastic Thickness:
Volara Thickness:
Velcro #:
Soling:
Insert:
Other Combination:
Special Instructions:
Cast Modifications:
Ankle:
Forefoot:
Special Instructions
Transcription fees apply
Activity Level
Clinical Observation
Ankle:
Forefoot:
Diagnosis
Primary reason for the device
Closure Type:
Color:
Measurements:
(Measured from base heel to top)
Tongue:
Include reinforced anterior shell tongue?
Soling:
Include S.A.C.H. heel and rocker sole?
Insert:
Other Combination:
Cast Modifications:
Correct Ankle to 90°:
Forefoot:
Special Instructions
Transcription fees apply
Repair Options
Forefoot Posting
Type
L
Degrees
R
Degrees
K Wedge (1st Ray Cutout)
1st Met Cut Out
Rearfoot Posting
Type
L
Degrees
R
Degrees
Heel Lift
L
R
Plate Modifications
Decrease Arch
Increase Arch
Decrease Heel Cup
Narrow Device
Shorten Device
NOTE: LAB STANDARDS APPLY WHEN FORM IS INCOMPLETE.
Additions
Arch Reinforcement
Heel Pad
Met Pad
Met Bar
Scaphoid Pad
Padded Flange
Toe Filler
Padding
Accommodations
Please clearly mark the location of cut outs, channels, balance pads, dells, etc.
Balance Pad
Dancer's Pad
Morton's Ext Pad
Top Covers
Top Cover Length
* Upgraded top cover charges apply
Notes
Transcription fees apply