Mile High Balance Brace Order Form 4970 MONACO ST. UNIT A COMMERCE CITY, CO 80022 OFFICE: 303.289.1534 TOLL FREE: 866.710.4880 FAX: 303.288.3687 www.mholabs.com Ship To Same as Bill Address: Account Name: 0□ Posterior Tibial Tendon Dysfunction (PTTD) □ Degenerative Joint Disease □ Severe Pronation □ Right □ Bilateral □ Black Closure Type: □ All Velcro® Height: (Measured from base Heel to top of collar) □ As Marked on Cast □ Other________ Cast Modifications: □ Correct to 90° □ Leave as Casted Forefoot: □ Correct to Neutral □ Leave as Casted Ankle: * All Cast Will Be Corrected To Subtalar Neutral Unless Specified Otherwise Please Call For Consult