bodi line

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

Slim

3mm Co-Polymer
No Stabilizer
Ultra Hyde Met Length
Top Cover 1/16"

Shallow Heel Cup

Contour

55 Durometer EVA
Vinyl Bottom Covers
Neoprene Full Length
Top Covers 1/8"

Standard Heel Cup

Venture

3mm Polypropylene
With Stabilizer
Ortho-Lite Full Length
Top covers 1/8"

Vinyl Bottom Covers
Standard Heel Cup


Optional Changes or Additions

Top Covers

Cover from heel to:
Thickness (inches):
Materials:

Bottom Covers

Thickness (inches):
Materials:

Accommodations

Region Foot
2-4 Met Pad
Heel Spur Pad
Region Foot
Met Bar
Heel Cushion

Heel Cups

Heel Cup:

Rearfoot Posting

Forefoot Intrinsically Posted and Balanced
Left Varus:
Left Valgus:
Right Varus:
Right Valgus:

Heel Raise

Left:
Right:

Additional Notes

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