PLACE ACCOUNT LABEL HERE PREMIER PATIENT INFORMATION Name Shoe Size* Male Female Date of Birth Weight Shoes / Insoles Enclosed Previous Rx# Date SHIPPING INFORMATION IF SHIP TO PATIENT OR LOCATION OTHER THAN BAR CODE. Street Address City State & ZIP Physician’s Signature P.O. Number ORDER OPTIONS ADDITIONAL CHARGES WILL APPLY Return Positive Molds SOLO Boxes US Mail Labels ________ UPS Labels __________ RUSH upgrade: Next Business Day 3 Business Days OVERNIGHT SHIPPING RUSH CHARGES DO NOT INCLUDE OVERNIGHT SHIPPING Mail-to-Patient INCLUDE SHIPPING ADDRESS (TO THE RIGHT) FUNCTIONAL Polypropylene shell by patient weight, extrinsic rearfoot post, standard heel depth, and orthotic width, Leatherette top cover to mets Cobra Shadow Cork (Shell to toes, standard heel depth, molded Plastizote top cover to toes) Heel Pad L R Horseshoe Pad L R Met Pad L R Soft Firm 1/16" 1/8" 3/16" Met Bar L R Soft Firm 1/16" 1/8" 3/16" Scaphoid Pad L R Soft Firm 1/16" 1/8" 3/16" Lateral Flange L R Lateral Clip L R Heel Depth X-Deep, 18 mm Deep, 15 mm Standard, 12 mm Low, 8 mm Shell Width Wide Standard Narrow Hourglass POSTING Forefoot No Post Intrinsic Extrinsic Tip Posts To Casts L __________ varus / valgus R __________ varus / valgus L _________________ varus / valgus Runner’s Wedge R _________________ varus / valgus Rearfoot No Post Intrinsic Extrinsic To Vertical (low profile) L __________ varus / valgus R __________ varus / valgus Heel Lift Korex Crepe In Increments L _________" inches R _________" inches Top Cover Length To Toes To Sulcus To Mets No Cover TOP COVER (choose 1) Leatherette, Vintage Burgundy Leatherette, Cherry Red Leatherette, Saddle Brown Leatherette, Onyx Black Leatherette, Smoke Gray Neoprene 1/16” Neoprene 1/8” Plastizote EVA 1/16" EVA 1/8" Leather 1st Met Cut Out L R K Wedge L R Morton’s Ext. in shell L R Turf Toe L R Shell Rigidity Flexible Semi-Flexible Semi-Rigid Rigid OR Indicate Specific Polyproplene Thickness STANDARD DRESS Polypropylene shell by patient weight, intrinsic rearfoot post, x-low heel depth and hourglass width, Leatherette top cover to mets EVA Shell Leather Shell (Shell to mets, leather top cover to toes) Firm Plastizote Shell X-Low, 5 mm Medial Flange/Platform Low Medium High Mini Platform L R Standard Platform ACCOMMODATIVE Notes PAIHO ® Bamboo 1/8” Private Label Top Cover Dri-Brelle ® UPGRADED TOP COVER E Left Right TOE FILLER D Standard Reduced Bulk ARCH REINFORCEMENT B L R INTRINSIC HEEL PAD OPTIONAL UPGRADES ADDITIONAL CHARGES APPLY. SEE PRICE LIST. UPGRADED PLATE A RX-A RX-B RX-C Performance Rx Engineered Nylon 2 mm 2.5 mm 2.9 mm Carboplast II Graphite 1.25 mm 1.4 mm DBX Graphite ADDITIONAL ACCOMMODATIONS C Padding Soft Firm 1/16" 1/8" 3/16" L R Cut Out 1/16" 1/8” 3/16" L R 1/16" 1/8” 3/16" Channel L R LEFT RIGHT 1 2 3 4 5 1 2 3 5 4 Lab Standards apply when order form is incomplete. *If shoe size is not supplied, any repair charges needed will be applied Mets Sulcus Toes Distal to Sulcus Distal to Toes Balance Pad Soft Firm 1/16" 1/8" 3/16" Dancer’s Pad Soft Firm 1/16” 1/8” 3/16” Morton’s Ext Pad Soft Firm 1/16” 1/8” 3/16” L R L R L R 415 South Laurel Street, Kutztown, PA 19530 | 800-765-6522 | Fax 610-683-6427 | www.sololabs.com UPDATED 8/23/19 Barcodes Order Forms Padded Flange L R