Custom Shoe Work Order - Rightwaycm
Download a blank fillable Custom Shoe Work Order - Rightwaycm in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Custom Shoe Work Order - Rightwaycm with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
23825 Investment Ln. Suite # 10 Riviera Beach, Fl. 33404 Phone (561) 840-6792- Fax (561) 840-6799
To serve properly, please fill form out completely and legibly.
Custom shoe work order
COMPANY NAME: ____________________________
SHIP TO: ______________________________________
Phone: ___________________ Fax: _________________
Purchase Order # __________
Address ________________________________________
Date: ____________________ Account # ____________
City ______________ State ______ Zip. ______________
PRACTITIONER NAME: _______________________
DIAGNOSIS
L
R
Diabetic ____ Toes Overlapped
____
____
Post Polio ___
Hammered
____
____
_______________________________________________
Amputee ___ Arch No Deformity
____
____
Charcot ____ Flexible Deformity
____
____
PATIENT NAME:______________________________
Arthritic ____ Rigid Deformity
____
____
Male______ Female______ Age______ Weight £______
Other: __________________________________________
Occupation: ____________________________________
Had Rightwaycms before ___________ Date __________
CAST MODIFICATION
REMOVABLE CUSTOM MOLDED INSERTS
Correct Cast to 90° ______
Standard: ¼” Pink + ¼” White Plastazote®____________
Standard Toe Elongation ( ¾)________
¼” Pink + 1/8” Poron® + ¼” White Plastazote®*_______
Extra Toe Elongation ( ¼ ) _________
Cover* Leather*_____ Spenco®*_____ Poron®*______
High Toe Box ________ Extra High Toe Box _________
Extra Inserts 1 pair*_________ 2 pairs** _____________
Duplicate Cast* ______ Other _____________________
Other: _________________________________________
SHOE STYLE ________________ Color___________
SPECIAL LINING
Heavy Duty Leather* _______
OPENING
B-foam Cushion (standard) _____
Regular _______ Semi-Surgical______ Surgical_______
Full Leather*_____
Velcro®* 1 _____ 2 _____
Laces _____________
Plastazote® * _______
Velcro D-ring Normal Direction ( Standard )
Vamp* _______
L
R
Heel* ________
Velcro D-ring Reverse Direction
______ ______
Collar and Tongue come padded Standard Unless
Velcro Flat Normal Direction
______ ______
Otherwise Noted
Velcro Flat Reverse Direction
______ ______
Collar ( no padding ) ____ Tongue ( no padding )____
T-Strap* _______
______ ______
Hook* _______ Speed Lace* _______
Other: _______________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business