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2010 prescription order form

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This is a copy of TOG Orthotics prescription form. Please complete it and send it in with your foam cast impressions.

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2010 prescription order form

  1. 1. PRESCRIPTION ORDER FORM For Office Use Only LAB ADDRESS: 160 Markland Street Markham ON L6C 0C6 Canada Order # Tel: 1.800.551.3008 Toll Free Fax: 1.877.551.3001 Toll Free 2nd Pair Fax: 1.877.551.3010 Date: www.theorthoticgroup.com PRACTITIONER/CLINIC INFORMATION PATIENT INFORMATION Name Name TOG Account # Age Weight Gender Address Activity/Occupation Shoe Type Shoe Size Phone CHIEF COMPLAINTS/NOTES Fax Plantar View Email EXAMINATION FINDINGS Arch Height (non-weight bearing) Supination Pronation Left Right High Medium Low Arch Height (weight bearing) Left Right High Medium Right Foot Right Foot Low Right Left Left Right Left Right Mild Mild Gait Moderate Moderate Toe in Straight Toe out Severe Severe OPTIONAL FINDINGS Ankle Left Right General Left Right Forefoot varus Left Right Dorsi-Flexion Mild Foot Motion Moderate Adequate Restricted Severe PLEASE SEND Limited Normal Hyper-mobile Forefoot valgus Left Right 6 Pack of Foam Casting Kits GaitScanTM Brochures Mailing Labels Mild Footwear Brochures 25 Pack of Foam Casting Kits Canada Moderate Severe 50 Pack of Foam Casting Kits Heel Lifts - with 4 lifts A,B,C,D United States Box of Plaster (50 slabs) Ladies Narrow (Size 1 = 5.5 cm) ORDER INFORMATION 6 Pair Pack of slipper socks Ladies Regular (Size 2 = 6 cm) includes 1S, 2M, 2L, 1XL Men’s Narrow (Size 3 = 6.5 cm) RUSH ($25 additional charge) Shoes Enclosed 1 Pair Size_______ Men’s Regular (Size 4 = 7 cm) Total # of Pairs: Insoles Enclosed RX Forms Foot Care Brochures Clinic Pack- with 16 lifts included Fabricate 2nd Pair from Cast on File Insole Tracing Enclosed Date of Original: (on file for 2 years) Suede Leather Topcover on Orthotic ($10 additional charge) Repair/Adjustment Footwear Exchange ADDITIONS/MODIFICATIONS ORTHOTICS CASUAL 2mm 3mm 3.5mm 3/4 sulcus full length SuperFlex N/A KidsFlex* N/A Reverse Morton’s Extrinsic Forefoot Extrinsic Forefoot *Children less than 60lbs or younger than 6 years old. Full Heel Cushion Extension Post (Sulcus length) Post (3/4 length) (1mm only) CushionFlex N/A L ____ R ____ L_____° R_____° L_____° R_____° 2mm 3mm 3.5mm 3/4 sulcus full length DRESS DressFlex Heel Spur Pad Deep Heel Cups FashionFlex N/A N/A Heel Lift L_____ R_____ Forefoot Pad L____mm R____mm to Sulcus 2mm 3mm 3.5mm 3/4 sulcus full length (10mm maximum) L_____ R_____ SPORT SportFlex RunFlex N/A EagleFlex Hole in Heel Sub-Metatarsal SkiFlex † N/A L ____ R ____ Accomodation Medial Flange SkateFlex † N/A With foam disk Reinforced Arch L____Metatarsal L_____ R_____ CourtFlex † N/A (greater than 280 lbs) R____Metatarsal Lateral Flange SoccerFlex † N/A L_____ R_____ SafetyFlex † N/A † Please send photocopy or tracing of insole SPECIALTY ORTHOTICS Metatarsal Pad Neuroma Pad Low Profile Rearfoot Extrinsic Post L____Interspace UCBL 3/4 length only - 1mm black naugahyde topcover 1mm 2mm Special Features: High medial and lateral flanges and deep heel cups Distal Placement L_____° R_____° R____Interspace Medial Skive L____mm R____mm Lateral Skive GAIT PLATE 3/4 length only 2mm 3mm 3.5mm L____mm R____mm 1mm black naugahyde topcover Induce toe out Induce toe in Extra Foam Padding Vinyl Sandwich Morton’s Extension under Topcover DIABETIC FLEX 3/4 sulcus full length 1st Metatarsal Cut-Out L_____ R_____ Accommodative orthotic cast L ____ R ____ 1/8” 1/16” should be taken weight bearing L______ R______ FOOTWEAR (Please select footwear from the reverse side of yellow copy) Footwear ___________________________________________ Footwear only (no orthotic) Footwear ___________________________________________ Footwear only (no orthotic) Size _________________________________________________ Women’s Men’s Size _________________________________________________ Women’s Men’s Colour ___________________________________________________________________ Colour ___________________________________________________________________ Orthotic Thickness* Shoes: 2mm 3mm 3.5mm *1mm thickness applies to all Sandals Orthotic Thickness* Shoes: 2mm 3mm 3.5mm *1mm thickness applies to all Sandals Standard Orthotic Other Orthotic: (please specify) ______________________________ Standard Orthotic Other Orthotic: (please specify) ______________________________ Name of Insurance Company: _______________________________________________________________________________________________________ Practitioner's Signature:______________________________________________________________ Date: _____________________________________________________ Send white copy to TOG. Keep Yellow copy. Last updated March 2009
  2. 2. FOOTWEAR (Please fill out the footwear section on the bottom of the white copy) WOMEN’S SHOES MEN’S SHOES Hi-Tec Outdoor - Chocolate *(5-10,11) ® Dr. Martens ® Classic - Black (4-13) Hush Puppies® Formality - Black, Brown *(5-10,11) Florsheim ® Austin - Black *(8-11,12) Hush Puppies® Optima - Black *(6-10) Brown *(7-10) Florsheim ® Corbin - Black, Brown *(7-12,13) Hush Puppies® Journey - Black *(5-10,11) Florsheim ® Cornell - Black, Brown *(7-12,13,14) Hush Puppies® Talini - Black *(5,7-10,11) Florsheim ® Jamie - Black, Brown *(7-12,13,14) Hush Puppies® Tatyana - Black *(6-10,11) Florsheim ® Jesse - Black *(7-12,13,14) Hush Puppies® Wildwood - Black (6-10) Florsheim ® John - Black *(7-12,13,14) Keen® Calistoga - Black, Brown *(6-11) Florsheim ® Radar - Black, Brown *(7-11,12,13,14) Keen® Presidio - Brown *(5-11) Florsheim ® Relay - Black, Brown *(7-12,13,14) Magnum® 6” Non-Safety - Black *(5.5-10,11) Hi-Tec ® Outdoor - Chocolate *(7-12,13,14) Magnum® 8” Non-Safety - Black *(5-10,11) Keen® Austin Lace - Black, Brown *(7-12,13,14) Merrell® Tetra Fling - Black *(5-10,11) Keen® San Antonio - Green *(7.5-12,13) Merrell® Tetra Lace - Black *(5-10,11) Magnum ® 6” Non-Safety - Black *(7-12,13,14) Merrell® Tetra Sprite - Black *(5-10,11) Magnum ® 8” Non-Safety - Black *(7-12,13,14) Merrell® Tetra Wave - Black *(5-10,11) Merrell ® Encore Clog - Black *(7-12,13) Merrell® Barrado - Black, Brown *(5-10,11) Merrell ® Jungle Moc - Gunsmoke, Taupe *(7-12,13) Merrell® Jungle Moc - Black *(5-10,11) p.w. minor ® Performance Walker Lace - Black, White Merrell® Solana - Black *(5-10,11) p.w. minor ® Performance Walker Strap - Black p.w. minor® Leisure - Black, Taupe p.w. minor® Widths- Regular, Wide, Extra Wide & XX Wide *(7-13,14,15) p.w. minor® Maddie - Black TOG Liberty - Black (9-11) Diabetic Option also available p.w. minor® Performance Walker Lace - Black, White, Clay TOG Nixon - Black (11-13) p.w. minor® Performance Walker Strap - Black, White TOG Sutton - Black (7-13) Brown (7-11) p.w. minor® Sienna - Black *available in half sizes p.w. minor® Tory - Black MEN’S ATHLETIC SHOES p.w. minor® Tribeca Boot - Black p.w. minor® Widths- Narrow (7-12) Regular, Wide & Extra Wide (5-12,13) XX Wide (6-12,13) AND1® Mid-Point - White w/Black *(7-11,12,13,14) Sebago® Courtyard - Black, Brown *(5-10,11) Brooks® Adrenaline - White w/Silver & Ink Blue *(7-13,14) Regular, Wide & Narrow TOG Avenue - Black (6,7,9,10) Brooks® Beast - White w/Silver & Blue *(8-13,14) Regular, Wide & Extra Wide TOG Crescent - Black (6-11) Brooks® Dyad - White w/Silver & Orange *(8-13,14) Regular & Wide TOG Liberty - Black (6-9) Diabetic Option also available Brooks® Glycerin - White w/Silver & Ink Blue *(8-12,13,14) TOG Onward - Black (6-8) Stone (6-10) Brooks® Infiniti - White w/Metallic Gold & Black *(8-13,14) TOG Studio - Black (36-42) Brooks® Trainer - Black, White, Brown *(7-12,13) *available in half sizes Fila® Prevail - Black, White *(7-11,12,13) WOMEN’S ATHLETIC SHOES Hi-Tec® Multiterra - Grey *(7-11,12,14) Hi-Tec ® Outdoor - Chocolate *(7-12,14) Brooks® Adrenaline - White w/Ink Blue & Silver Narrow & Regular *(5-11,12) Wide *(6-11) Hi-Tec® Typhoon Golf - White w/Black *(7-12,13) Brooks® Ariel - White w/Blue & Silver Regular *(6-11,12) Wide & Extra Wide *(7-11,12) Merrell® Moab - Walnut *(7-12,13) Brooks® Dyad - White w/Blue & Silver Regular *(6-11) Wide *(7-11) UMBRO® Xai Premier Soccer - Black w/White *(7,8-9.5,10.5-12,13) Brooks® Glycerin - White w/Blue & Silver *(6-11) *available in half sizes Brooks® Infiniti - White w/Red & Silver *(6-11) MEN’S SANDALS/CLOGS Brooks® Trainer - White, Black *(5,6-9,10) Hi-Tec® Outdoor - Chocolate *(5-10,11) Bite ® X-Trac - Coffee (7-13) Hi-Tec® Multiterra - Charcoal w/Plum *(5,6-9.5) Bite ® Boomerang - White w/Black (7-14) Hi-Tec® V-Lite Golf - White w/Blue *(5,7-9,10,11) Birkenstock® Arizona - Black,Taupe (36-50) **Made to order. See below for restrictions Merrell® Siren - Desert Sage *(5-10,11) Birkenstock® Milano - Black, Cocoa (36-50) **Made to order. See below for restrictions *available in half sizes Merrell ® Encore Clog - Black (7-12,13) WOMEN’S SANDALS/CLOGS NAOT ® Lapland - Brown (40-47) NAOT ® Gandalf - Brown (40-47) Bite® Spirit - Black, Blue (5-11) NAOT ® Fjord Clog - Brown (40-47) Bite® X-Trac - Tea (5-11) TOG Safari - Black (39,41-43,45) Espresso (39,41,42,45) Bite® Boomerang - Black (5-11) TOG Muskoka - Charcoal (40-43,46) Espresso (39,40,42-46) Birkenstock® Arizona - Black,Taupe Narrow & Regular (36-50) TOG Hampton - Black (39-45)Tan (39-46) **Made to order. See below for restrictions *available in half sizes Birkenstock® Florida - Cocoa Narrow & Regular (35-42) MEN & WOMEN’S SAFETY SHOES/BOOTS **Made to order. See below for restrictions Birkenstock® Milano - Black,Cocoa Narrow & Regular (36-50) CAT® Men’s Activator Safety Runner - Black *(7-11,12,13) **Made to order. See below for restrictions CAT® Men’s Composite Lo Safety Shoe - Black *(7-11,12,13) Brooks® Tacoma - White w/Blue (5-11) CAT® Men’s Composite HI Safety Boot - Black *(7-11,12,13) NAOT® Geneva - Black, Brown (35-42) CAT® Men’s Endure Safety Boot - Black, Brown *(7-11,12,13) NAOT® Hazel - Black (35-42) CAT® Women’s Kitson Safety Boot - Black *(5-9,10) NAOT® Karenna - Black, Brown (35-42) Geronimo® Men’s Oxford Lo Safety Shoe - Black *(7-11,12,13) NAOT® Marla - Black, Pecan (35-42) Geronimo® Women’s Oxford Lo Safety Shoe - Black *(5-9,10) NAOT® Nebraska - Metal (35-42) Geronimo® 6” Men’s Safety Boot - Black *(7-11,12,13) NAOT® Paris - Black, Metal (35-42) Geronimo® 8” Men’s Safety Boot - Black *(7-11,12,13) NAOT® Pisa - Black (35-42) Geronimo® 6” Men’s w/Toe Cap Safety Boot - Tan *(7-11,12,13) NAOT® Tammy - Black (35-42) Geronimo® Men’s Safety Runner - Charcoal *(7-11,12,13) NAOT® Rome - Black (35-42) Magnum ® 6”Men’s Safety Boot - Black *(3,4,5-11,12,13,14) NAOT® Willow - Black (35-42) Magnum ® 8”Men’s Safety Boot - Black *(3,4,5-11,12,13,14) NAOT® Vega- Black (35-42) *available in half sizes NAOT® Viola - Brown (35, 37-41) CHILDREN’S SHOES/BOOTS Spring Step® Kaylana - Black, Brown (35-42) TOG Addisson - Black, Sand (35-42) Brooks® Girl’s Adrenaline - White w/Pink (1-6) TOG Aviara - Black (35-39) Brooks® Boy’s Adrenaline - White w/Blue (1-6) TOG Boca - Black (35-38) Chocolate (35-37) Fila® Jr. B-Ball - Black (11,12,13,1-6) TOG Cape - Black (36-42) Hi-Tec® Jr. Outdoor - Chocolate (13,1-6) TOG Clog - Black (36-41) Cocoa (36-39,41) Merrell® Jr. Jungle Moc - Taupe, Gunsmoke (13,1-6) TOG Everywear - Black (36-39) Stone (36-42) Umbro® Xai Jr. Premier Soccer - Black (13,1-6) TOG Muskoka - Charcoal, Chocolate (35-42) Olive (35-38,40) *available in half sizes TOG Nightingale - White (36-42) AVAILABLE WHILE QUANTITIES LAST TOG Safari - Black, Chocolate (35-42) Olive (35-39,41,42) TOG Studio - Black (36-42) WOMEN’S TOG Soho - Black (35,36,39,41) Bite® Tempo - Grey (6-10) TOG Tahoe - Black, Cocoa (35-42) Bite® Twilight - Sand (5,6,8) TOG Tonic - Black (36, 38-42) Hush Puppies® Daisy - Black (5.5,7,11) TOG Troon - Black (35-42) Sand (35-39,42) Merrell® Cold Front - Black (7-8) *available in half sizes TOG Nellie - Black (7,8) CROCS® RX LINE TOG Slide - Chocolate (36, 37) Black (37) TOG Palmetto - Black, Brown (10,11) CROCS® Women’s Custom Cloud - Black, Chocolate Wide & Extra Wide*(6-13) TOG Ginger - Black (8-10) CROCS® Men’s Custom Cloud - Black, Chocolate Regular & Wide *(4-13) TOG Sloan - Black (35) *available in half sizes MEN’S Brooks® Crosscourt - White (9) Brooks® Basketball - Black (9,9.5) Brooks® Vapour Steel Toe Safety - Grey (10,11) Florsheim® Tamarack - Black (10.5,11,14) SANDAL/SHOE SIZING INFORMATION Hush Puppies® Corvette - Black (8,10) Women’s Sizes: Euro (CAN/US) TOG Pilot - Black (7,9,11,13) TOG Yukon - Tan (4,9) 35(4) 36(5) 37(6) 38(7) MEN & WOMEN’S 39(8) 40(9) 41(10) 42(11) TOG Truimph Men’s - White (9,10) Women’s - White (6-8) TOG Trainer Men’s - White (8-13) Women’s - White (8) Men’s Sizes: Euro (CAN/US) Men’s - Black (11-13) CHILDREN’S 36(3) 37(4) 38(5) 39(6) Hi-Tec Jr. Multiterra - Chocolate (4,5,6) ® 40(7) 41(8) 42(9) 43(10) FOOTWEAR RETURN/EXCHANGE POLICY 44(11) 45(12) 46(13) 47(14) In a few cases you may find that the size of the footwear you ordered may not be the exact fit for your patient, as they have not had the opportunity to try on the product prior to purchase. For this reason we offer a no-fee service Youth’s Sizes: CAN/US to exchange the size or style within thirty days of purchase, provided the footwear has not been worn. If you require 13 1 2 3 4 5 6 The Orthotic Group to re-issue a new size or style, please send the original footwear back to the laboratory (free from wear) along with the orthotic insert/footbed. If no exchange for size or style is required and you are just Additions and modifications are available on orthotic inserts and sandal footbeds. Limitations may apply. returning the footwear for a refund, a credit will be issued to you on your next accounting statement. 1mm orthotic thickness applies to all sandal footwear. **Please note, Birkenstock sandals are made to order and are not eligible for full credit. A re-stocking fee of Please contact our Customer Service Team toll free at 1-800-551-3008 for further assistance. the shell only price of the sandal will be charged to your account for either an exchange or a return. For updates on our footwear line please visit our website at www.theorthoticgroup.com.

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