6324 Bass Lake Road, Suite D Crystal, MN 55428 Email: Thomas@topfinc.com www.topfinc.com ORDER INFORMATION DATE P.O. # PATIENT NAME: FACILITY: Age: Sex: Height: Weight: Address: Shoe Size: Diagnosis Contact Name: Ship via: Phone #: Fax #: Requested Date of Delivery: NEXT DAY AIR 2ND DAY AIR 3RD DAY AIR GROUND Impression Kit Slipper Casts Pair Single Right Left UCB Dress Shoe Style Custom Diabetic Insert Indicate Material: Plastic Firm Puff Soft Puff Cork XPE Other Material Modifications Deep Heel Cup Right Left High Medial Flange Right Left High Lateral Flange Right Left Arch-Increase mm Decrease mm Length of Orthosis: Full-length Sulcus Length Other Posting Instructions Post according to lab evaluation No posting REARFOOT Varus Valgus Heel Lift Right mm, or in. Left mm, or in. Store Casts (15 days) Return Casts Download Form
