Custom Shoes OrdFrm

ARIZONA AFO, INC.
4825 E. Ingram St, Mesa, AZ 85205
(877) 780-8382 Fax: (480) 461-5187
www.ArizonaAfo.com
CUSTOM SHOES
LOW TOP (Below Ankle)
COLOR:
SAND
CHUKKA (3” Above Ankle)
BLACK
BROWN
WHITE
CLOSURE:
LACES
OPTIONS:
Additional removable, multi-density insoles _____
VELCRO
BOOT HOOKS
PATIENT INFORMATION:
OTHER (If available)_________________
SPEED LACES
Padded Collar
LAST NAME,
Male
COMBO OF THOSE SELECTED
OTHER (If available)___________
PO#____________________
NAME: ________________________________________________________
AGE: ____________
HI-TOP (6”-8” Above Ankle)
HT: _________ WT: __________
FIRST NAME
Female
Right
Left
Bilateral
DX: ________________________________________________________________________________________________________
SHIPPING INFORMATION: PRACTITIONER: ___________________________________________________________
PHONE: _______________________
FAX: _________________________________
FACILITY: _____________________________________
SHIP TO:
BILLING ADDRESS: ____________________________________
_____________________________________
____________________________________
_____________________________________
____________________________________
SHIPPING INSTRUCTIONS:
GROUND
3 DAY AIR
2 DAY AIR
OVERNIGHT
OTHER: _____________________
SPECIAL INSTRUCTIONS:
LEAVE CAST AS IS
CORRECT ANKLE VARUS/VALGUS
CORRECT CAST 90º TO FLOOR
CORRECT FOREFOOT TO NEUTRAL
(if ankle and/or forefoot are correctable, it is highly recommended that you capture that at the time of casting to obtain best results)
REMARKS: ___________________________________________________________________________________________________________________________
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