PATHOLOGY ORTHOTICS

9960 Indiana Ave. Suite #15 Riverside, CA 92503 Phone: (951) 353-8127 Fax: (951) 353-8107

___ Pes Cavus Orthotic Description:• 3mm Polypro shell• RF Post Neutral Extrinsic• Deep Heel Cup• 3mm Black Spenco Top Cover To Toes• 3mm Eva Valgus Extension• Suede Bottom Cover To Toes

Patient Information: Patient Name: ____________________________ Address: __________________________________ City:_____________State:_______ Zip:_________Age:____Sex: M F Weight:____Shoe Size:_____

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Account InformationPractitioner: __________________________________Address:_____________________________________City:__________ State:___ Zip:____________Telephone:________________ Fax:________________

__Achilles Tendinitis Orthotic Description:• 3mm Polypro Shell• RF Post Neutral Extrinsic• Deep Heel Seat• 3mm Black Spenco Top Cover To Toes• 2mm Blue Poron Extension• 4mm Heel Lift: Relieve pressure on tendon

__Calcaneal ApophysitisOrthotic Description:

• 3mm Polypro Shell• Extra Deep Heel Seat• RF Post Neutral Extrinsic• 4mm Medial Heel Skive• 3mm Heel Lift: Relieve pressure on tendon• 3mm Black Spenco Top Cover To Toes• 3mm Heel Cushion

___Pes Planus-Flatfoot : (Device provides medial control) Orthotic Description:

• 3mm Polypro Shell• Deep Heel Seat• 4R RF Extrinsic• Medial Flange• 3mm Black Spenco Top Cover• 2mm Blue Poron Extension To

Toes

___Plantar Fasciitis Orthotic Description:• 3mm Polypro Shell• RF Post Neutral Extrinsic• Deep Heel Seat• 3mm Black Spenco Top Cover To Toes• 2mm Blue Poron Extension To Toes• Heel punch W/ Visco plug to reduce pain

*Additions:____2mm Heel Cushion & 3mm Heel Spur Pad (Max Cushion)____P.F. Groove

__ Sesamoiditis Orthotic Description:• 3mm Polypro Shell• Deep Heel Seat• RF Post Extrinsic 3 Degrees Varus• 2mm Medial Heel Skive• 3mm Reverse Morton's Extension• 3mm Black Spenco Top Cover To Toes• Suede Bottom Cover To Toes• 1st Ray Cut-Out

___Functional Hallux Limitus: Orthotic Description:

• 3mm Polypro Shell• RF Post Extrinsic 2 Degrees Varus• Deep Heel Seat• 4mm Medial Heel Skive• 3mm Reverse Morton's Extension• 3mm EVA Top Cover To Toes• Suede Bottom Cover To Toes

__ Neuroma Orthotic Description:

• 3mm Polypro Shell• Shallow Heel Seat• RF Post Intrinsic 2 Degrees Varus• Neuroma Pad 3rd Innerspace• 3mm Black Topper To Sulcus• 2mm Poron Extension To

Sulcus• Suede Bottom Cover To Sulcus

___MetatarsalgiaOrthotic Description:• 3mm Polypro Shell• Standard Heel Seat• RF Post Extrinsic 2 Degrees Varus• 3mm Met Bar• 3mm EVA Swirl Top Cover To Toes• 2mm Poron Extension To Toes

___Pediatric Flat Foot:Orthotic Description:

• 3mm Polypro Shell• Medial Flange• RF Post Extrinsic 4

Degrees Varus• Deep Heel Seat• 4mm Medial Heel

Skive• 3mm EVA Top

Cover To Toes

____Lateral Ankle Instability: Orthotic Description:

___ Gait Plate:Orthotic Description: • 3mm Polypro Shell Gait

Extension• Standard Heel Seat• RF Post Extrinsic Neutral

__Posterior Tibial Tendon Dysfunction:Orthotic Description:(Adult Acquired Flatfoot)

• 3mm Polypro Shell• Deep Heel Seat• Medial Flange• RF Post 4R Extrinsic• 3mm EVA Paisley Top Cover To Toes• EVA Medial Arch Filler

__Sinus Tarsi SyndromeOrthotic Description:

• 3mm Polypro Shell• Deep Heel Seat• RF Post Extrinsic Neutral• 4mm Medial Heel Skive• 3mm EVA Swirl Top Cover To Toes

__Tarsal Tunnel Syndrome Orthotic Description:

• 3mm Polypro Shell• Deep Heel Seat• RF Post Extrinisc 2 Degrees Varus• 4mm Medial Heel Skive• 4mm Heel Lift• 3mm EVA Swirl Top Cover To Toes

• Deep Heel Seat• 3mm Ploypro Shell• RF Post Neutral

Extrinsic• Medial Flange• Lateral Flange• 3mm Black EVA Top

Cover To Toes 3mm Valgus Extension

• Suede Bottom Cover to Toes

• RF No Lateral Undercut

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