Advantage

Account Information

Account Name: Clinic Email:

Patient Information

First Name:   Last Name:
Occupation:
Age:   Gender:
Height (ft.):   (in.):   Weight (lbs.):
Shoe Style 1: Shoe Style 2: Width: Shoe Size:
Notes:

Orthotic Type

Enter Other Product Type

Posting Instructions

Post according to lab evaluation
Post to these values
Calcaneal Vertical
Neutral Shell (as casted)
Arch Aggresiveness:
     Low
     Medium
     High

Shell Modifications

Modification Left Right
Shallow Heel Seat
Deep Heel Seat
Lateral Clip
Lateral Flange
High Medial Flange
1st Met Cut Out
1st Ray Cut Out
Cut Orthosis Narrower
Cut Orthosis Wide

Top Covers

(made to lab discretion unless specified)
Cover from heel to:
Thickness (inches):
Materials:
Bottom Cover (please detail):

Additional Extensions

Metatarsal heads to:
Thickness (inches):
Materials:

Accommodations

2-4 Met Pad
Neuroma Pad
FHL Accommodation
Heel Spur Pad
2-5 Extension
Met Bar
Heel Cushion
Intrinsic Heel Cushion
Scaphoid Pad
Morton's Extension

Additional Notes

Upload Foot Scans (.raw image files - 2MB limit)