Order Information

    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

    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)

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