Custom Crafted Orthosis Prescription

Custom Orthotic Orderform

The custom crafted laboratory prescription form was designed to allow the practitioner to create a truly customized orthosis to meet specific patient needs while also being “user friendly”.

The custom crafted laboratory prescription form was designed to allow the practitioner to create a truly customized orthosis to meet specific patient needs while also being “user friendly”. The initial portion of the form is for pertinent physician and patient information.

We stress the importance of including the patient’s shoe style and size with the shoe liner or outline tracing when possible. This greatly facilitates the fabrication process and aids in optimal shoe fitting.

The “Special Requests or Instructions” portion of the form may be utilized to elaborate on the patient’s foot pathology, activity level or specific orthosis modifications required to meet their individual needs. The selection of orthosis type, design modifications and balance specifications are discussed in detail in the following sections of this booklet.

Download or Print Custom Crafted Orthosis CMO Prescription Form