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Patient Details
First Name
Surname
Age
Size
Gender
Footwear Type
Orthotics
Podiatrist Details
Clinic
Podiatrist
PO No
Type / Heel Cup Shape
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Left Foot
Right Foot
Same As Left
Arch Fill Technique
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Left Foot
Inverted
Mid
Modified Root
As is @ 0
As is
Optional Arch Fill
CB
Right Foot
Same As Left
Inverted
Mid
Modified Root
As is @ 0
As is
Optional Arch Fill
CB
Intrinsic Correction (+Varus -Valgus)
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Left Foot
Rear Foot
Fore Foot
Right Foot
Same As Left
Rear Foot
Fore Foot
Length and Style
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Joey Prescription Tool
Left Foot
Right Foot
Same As Left
Shell Material
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Polypropelene
Carbon Fibre
EVA
Left Foot
Right Foot
Same As Left
Modifications
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Medial Heel Skive
Tri-Planer Heel Skive
No Plaster Fill B/W 1 and 5
Cuboid Notch
Plantar 5th Ray Grind
Plantar Fascial Accommodation
1st Ray Accommodation
1st Ray Cut-Out
Extra Heel Expansion
Medial Flare
Medial Wrap
Heel Aperture
Heel Stabiliser
Lateral Plantar Grind
Gait Plate
Shell Shape
Left Foot
Medial Heel Skive
Lateral Heel Skive
Tri-Planer Heel Skive
Intrinsic Met Dome
Cuboid Notch
Plantar 5th Ray Grind
Plantar Fascial Accommodation
1st Ray Accommodation
1st Ray Cut-Out
Extra Heel Expansion
Medial Flare
Medial Wrap
Heel Aperture
Lateral Plantar Grind
Gait Plate
Shell Shape
Shell Length
Mortons Extension
Sweet Spot
Tell us where?
Medial Longitudinal Brace Bar
Heel Stabiliser
Heel Lift
Postmotion Grind
Right Foot
Same As Left
Medial Heel Skive
Lateral Heel Skive
Tri-Planer Heel Skive
Intrinsic Met Dome
Cuboid Notch
Plantar 5th Ray Grind
Plantar Fascial Accommodation
1st Ray Accommodation
1st Ray Cut-Out
Extra Heel Expansion
Medial Flare
Medial Wrap
Heel Aperture
Lateral Plantar Grind
Gait Plate
Shell Shape
Shell Length
Mortons Extension
Sweet Spot
Tell us where?
Medial Longitudinal Brace Bar
Heel Stabiliser
Heel Lift
Postmotion Grind
Cover
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Left Foot
Right Foot
Same As Left
Padding
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Met Dome Size Chart
Left Foot
Right Foot
Same As Left
Other/Comments
Submit Impressions
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I'm Sending Foot Impressions
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Left Foot
Right Foot
Please ensure files are correctly uploaded for each foot.
Previous Order Number
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Clinic Name
Podiatrist Name
Bill To Address
Delivery Address
Dispatch Date
Delivery Type
Patient Details
Patient Name
Age
Shoe Size
Gender
Shoe Type
Orthotics
PO Number
Prescription Details
Type
Left Foot
Right Foot
Orthotic Type
Arch Fill Technique
Intrinsic Correction (+Varus -Valgus)
Length
Style
Shell Material
Modifications
Covers
Padding
Other/Comments
Declaration
I have checked that all details in this prescription are correct.
any changes beyond this point may incur a fee
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