6299 Guion Rd Indianapolis, IN 46268 800-444-3632 800-233-2280 fax www.alliedosilabs.com Account # ___________ Please place your account label here or fill in information CUSTOM PLUS LINE ORDER FORM FOR LAB USE ONLY Accommodations as marked on casts L_______________ Did you send shoes? Y N Shoe required for Turf Toe & Amputee Fill Ship to Patient (supply address & phone #) □ Return Casts Y N Account Name Account Address City State Last Patient Name □ New □ Second pair off previous mold RX #_________________ Please attach a separate order form for each pair Age______ Weight _______ Gender _____ Shoe Size ________ □ Adjustment □ Refurbish □ AOR Claim □ Rush 3-day (in lab) *Product standards will apply unless otherwise indicated FOREFOOT POSTING (Post to cast is standard unless otherwise indicated) (* indicates the product standard shell) Hybrid: Performance RX □ Semi-Flex Left: ____Varus ____Valgus Right: ____Varus ____Valgus Hybrid: Polypropylene REARFOOT POSTING □ No Post □ Mod Intrinsic □ Extrinsic □ Biaxial (> 6 degrees) □ No Post □ Intrinsic □ Extrinsic □ Triaxial (> 9 varus or 6 valgus) ATHLETIC CHILDREN'S LINE □ Whitman Roberts (Shoe required for Turf Toe or Amputee Fill) Additional Top Cover & Padding Options Heel Stabilizer : Gait Plate Inducing : Soft Poron® Padding: □ 1/16" (show accoms below) □ Intrinsic Shell Accom (as marked on cast) □ Shaffer Medial Grind Shell Color : □ 16mm* Deep Heel Cup □ Medial Flange Additional Cast & Shell Modifications Arch Height : Forefoot Width : Right: ____Varus ____Valgus Left: ____Varus ____Valgus Additional Comments or Instructions Extras (All accommodations are done bilaterally unless ortherwise indicated) Methead Accoms L_________________ R_________________ □ Met Pad Arch Reinforcements: □ Corex □ Horseshoe Heel Pad □ Hole in Heel □ Extra Heel Cushion Heel Lifts: (If requesting >1/2", additional material will be sent separately) For Lab Use Only : Place RX Sticker Here