Orthotic Order Form ›› denotes a required field. Patient:   ››  Gender:   ››  Male Female Daily Activity:   ››  Weight:   ››    ››  Lbs. Kgs. Type of Orthotic Left Right Rigid Rigid with Soft F/Part Semi-Rigid Semi-Rigid with Soft F/Part Soft Length of Orthotic Left Right Metatarsal Head Sulcus Full Length Cover Left Right Leather Leatherette Vinyl Spenco Plastazote Lunairmed PPT Accommodations Left Right Mortons Extension Plantar Facia Groove Metatarsal Pad Heel Spur Whitman Flange Heel Cup Other Material Left Right Rear Front Rear Front Carbon Fiber Subortholene Polypropolene Lunacell Ovacork Lunalight Lunasoft Lunaflex Lunairmed PPT EVA Plastazote Tepp Other:   Posting Instructions Left Right Medial Heel Lateral Heel Medial F/Foot Lateral F/Foot Intrinsic Extrinsic Degrees Other 1.5 mm 3.0 mm Special Instructions: The PDF version of this form is available for download by clicking here. Acrobat Reader can be downloaded by clicking on the Acrobat Image.

Johnson Bros. Shoes Ltd.     3015 Kennedy Road, Unit 6    Scarborough, On.  M1V 1E7
Phone: 416-297-8555      Toll free: 1-866-235-7277     Fax: 416-297-9227