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FUNCTIONAL ORTHOTIC ORDER FORM
Store ID#:
Required field
Clinician: Phone: Date:
PATIENT NAME First M.I. Last
Shoe Size Width Template #
Base Layer
Left Only Right Only
Top Layer
Middle Layer (optional)
3/4 Length
Male Female
SulcusFull Length
Standard (Decreased 1/8” from patient’s cast)
Total Contact (Made to patient’s cast)
Increased 1/8”from patient’s cast Other
CASTING MODIFICATION
ADVANCED OPTIONS
Quantity Ordered
GENDER
ARCH HEIGHT
TOP LAYER
TRIM LINES
HEEL POSTINGS
Put “1” for neutral post
Medial Wedge
Left Rightmm Medial Wedge mm
Lateral Wedge mm Lateral Wedge
Heel Lift mm Heel Lift
mm
mm
BASE LAYER
MID LAYER
1.5mm Spenco 2mm Poron
3mm Spenco 3mm Poron
Semi-RigidRigid
1/8” 1/8” 1/16”
Polypropylene CoPoly Graphite
3/16”
Flexible 1/16”
3/16”
1-877-229-9652 Arch Fitters 1625 SE Hogan Rd, Suite G Gresham, OR 97080
Special Instructions:
Contact E-mail:Additional charges may apply1
21
1
1
Pairs 2
High Medial Wall
High Lateral Wall
3 3
3Default 2
Both Left Right
NORMAL
LOW
DRESS
Both RightLeft
DEEP
UCBL
1
PLASTAZOTE
25 DM
35 DM
20 DM
15 DM
20 DM
1mm Black 1mm Brown
1.5mm25 DM
2mm Lt Blue Pu�
2mm Pink 3mm Pink
3mm Pink Pu�
3mm Lt Blue Pu�
3mm 4.5mm
3mm Blue
2mm Camo Swirl
2mm Pink Pu�
2mm Pink Swirl
2mm Blue Swirl
2mm Black Solid
2mm Blue
SPENCO (DUAL CLOTH)
NAUGAHYDE
35 DM
3mm Camo Swirl
3mm Pink Swirl
3mm Blue Swirl
3mm Black Solid
MICROCELL PUFF
MET-PADLeftBoth Right
Medium
Medium
Bar
Wide
Wide
Bar
Medium
Medium
Bar
Wide
Wide
Bar
Medium
Medium
Bar
Wide
Wide
Bar
STANDARD
AGGRESSIVE
HEEL CUP HEIGHT
1625 SE Hogan Rd Suite G, Gresham, OR 97080 Phone: 877-229-9652 Fax: 503-489-0706
www.archfitters.com
*Additional charges may apply, see your pricing plan for details or call 877-229-9652.
ARCH FITTERS TEMPLATE DIMENSIONS
Template Size Length Heel BOF Template Size Length Heel BOF1 (wms 5 mens 4) 9.16 2.186 3.231 13 (wms 5 mens 4) 9.16 2.268 3.3512 (wms 6 mens 5) 9.501 2.245 3.329 14 (wms 6 mens 5) 9.501 2.327 3.4493 (wms 7 mens 6) 9.842 2.304 3.427 15 (wms 7 mens 6) 9.842 2.386 3.5474 (wms 8 mens 7) 10.183 2.363 3.525 16 (wms 8 mens 7) 10.183 2.445 3.6455 (wms 9 mens 8) 10.524 2.422 3.623 17 (wms 9 mens 8) 10.524 2.504 3.7436 (wms 10 mens 9) 10.865 2.481 3.721 18 (wms 10 mens 9) 10.865 2.563 3.8417 (wms 11 mens 10) 11.206 2.54 3.819 19 (wms 11 mens 10) 11.206 2.622 8 (wms 12 mens 11) 11.547 2.599 3.917 20 (wms 12 mens 11) 11.547 2.6819 (wms 13 mens 12) 11.888 2.658 4.015 21 (wms 13 mens 12) 11.888 2.74 10 (mens 13) 12.229 2.717 4.113 22 (mens 13) 12.229 2.799 4.23311 (mens 14) 12.57 2.776 4.211 23 (mens 14) 12.57 2.858 4.33112 (mens 15) 12.911 2.835 4.309 24 (mens 15) 12.911 2.917 4.42949 (mens 16) 13.252 2.894 4.407 52 (mens 16) 13.252 2.976 4.52750 (mens 17) 13.593 2.953 4.505 53 (mens 17) 13.593 3.035 4.62551 (mens 18) 13.934 3.012 4.603 54 (mens 18) 13.934 3.094 4.723
X-WIDE: WOMENS 2E, MENS 4E
MEDIUM: WOMENS B, MENS D WIDE: WOMENS D, MENS 2E
XX-WIDE: WOMENS 4-E-6E, MENS 6E-8E
Template Size Length Heel BOF Template Size Length Heel BOF25 (wms 5 mens 4) 9.16 2.35 3.471 37 (wms 5 mens 4) 9.16 2.432 3.59126 (wms 6 mens 5) 9.501 2.409 3.569 38 (wms 6 mens 5) 9.501 2.491 3.68927 (wms 7 mens 6) 9.842 2.468 3.667 39 (wms 7 mens 6) 9.842 2.55 3.78728 (wms 8 mens 7) 10.183 2.527 3.765 40 (wms 8 mens 7) 10.183 2.609 3.88529 (wms 9 mens 8) 10.524 2.586 3.863 41 (wms 9 mens 8) 10.524 2.668 3.98330 (wms 10 mens 9) 10.865 2.645 3.961 42 (wms 10 mens 9) 10.865 2.727 4.08131 (wms 11 mens 10) 11.206 2.704 4.059 43 (wms 11 mens 10) 11.206 2.786 4.17932 (wms 12 mens 11) 11.547 2.763 4.157 44 (wms 12 mens 11) 11.547 2.845 4.27733 (wms 13 mens 12) 11.888 2.822 4.255 45 (wms 13 mens 12) 11.888 2.904 4.37534 (mens 13) 12.229 2.881 4.353 46 (mens 13) 12.229 2.963 4.47335 (mens 14) 12.57 2.94 4.451 47 (mens 14) 12.57 3.022 4.57136 (mens 15) 12.911 2.999 4.549 48 (mens 15) 12.911 3.081 4.66955 (mens 16) 13.252 3.058 4.647 58 (mens 16) 13.252 3.14 4.57156 (mens 17) 13.593 3.117 4.745 59 (mens 17) 13.593 3.199 4.66957 (mens 18) 13.934 3.176 4.843 60 (mens 18) 13.934 3.258 4.767
TODDLER
Template Size Length Heel BOF
Template Size Length Heel BOF
61.255.170.5)Toddler4( 1622.26.114.5)Toddler5( 2623.256.137.5)Toddler6( 3693.27.160.6)Toddler7( 465.257.14.6)Toddler8( 5675.28.127.6)Toddler9( 66
YOUTH
95.258.160.7)Toddler 01( 7676.29.14.7)Toddler 11( 8677.259.147.7)Toddler 21( 9638.2270.8)Toddler 31( 0729.250.24.8)htuoY 1( 1710.31.237.8)htuoY 2( 2780.351.260.9)htuoY 3( 37
4.0373.939
4.135