Online Prescription Form Your name Your email 1 2 First Name Last Name Metatarsal Adductus Metatarsal Adductus Valgus Valgus Limitus Limitus Rigidus Rigidus High High Medium Medium Low Low Rear Foot Varus Rear Foot Varus Rear Foot Valgus Rear Foot Valgus Pes Planus Pes Planus High_2 High_2 Medium_2 Medium_2 Low_2 Low_2 Out toe Out toe In toe In toe Straight Straight Fore Foot Valgus Fore Foot Valgus Fore Foot Valgus_2 Fore Foot Valgus_2 Pes Cavus Pes Cavus 1 TYPES OF ORTHOTICS SPORT MEDIXMARATHONSUPER FLEXSAFETY MEDIX CASUAL MEDIX CASUAL MEDIX DRESS DRESS HIGH HEEL HIGH HEEL ACCOMMODATIVE ACCOMMODATIVE DIABETIC DIABETIC EVA EVA Polypropylene Thin Polypropylene Thin UCBL UCBL ROBERT WHITMAN ROBERT WHITMAN Cork Cork Induce intoeing Induce intoeing Induce outtoeing Induce outtoeing undefined XT SPORT MEDIX XT SPORT MEDIX XT CASUAL MEDIX XT CASUAL MEDIX XT DRESS MEDIX XT DRESS MEDIX Heel Cup Depth 10mm12mm 15mm 15mm Other Other undefined_2 Min Min Moderate Moderate Max Max Standard Standard Wide Wide Narrow Narrow Black Black Navy Navy Black_2 Black_2 Tan Tan Brown Brown Varus Varus Valgus_2 Valgus_2 Extrinsic Extrinsic Intrinsic Intrinsic Suede Black_3GreenRedNavy_2 1 mm 1 mm 2 mm 2 mm 3 mm 3 mm Other_2 Other_2 Varus_2 Varus_2 Valgus_3 Valgus_3 undefined_3 1_2 2_2 Length undefined_4 Extrinsic_2 Extrinsic_2 Intrinsic_2 Intrinsic_2 Vinyl Black_4Navy_3Brown_2Red_2Grey Spenco Black_5Blue ETC Black_6Navy_4 Kids PPNWGRYN Full Length Full Length Sulcus Sulcus Varus_3 Varus_3 Varus_4 Varus_4 Valgus_4 Valgus_4 Valgus_5 Valgus_5 EVA Perforated Black_7Beige Microcell Black_8Navy_5Red_3Green_2Brown_3Yellow Leather Black_9Brown_4Beige_2 Suede_2 Black_10Tan_2Brown_5 34 to Mets 34 to Mets 1_3 2_3 1_4 2_4 Ext to Sulcus Ext to Sulcus Cushion Mid Layer None None 2 mm_2 2 mm_2 Left Left mm 3 mm_2 3 mm_2 Extra Extra Black_11 Black_11 Bamboo undefined_5 undefined_5 Right Right Left_2 Left_2 Right_2 Right_2 Left_3 Left_3 Right_3 Right_3 Left_4 Left_4 Right_4 Right_4 Met Pad Met Pad Met Bar Pad Met Bar Pad Left_5 Left_5 Right_5 Right_5 Heel Spur Pad mm_2 Left_6 Left_6 Left_7 Left_7 Left_8 Left_8 Left_9 Left_9 Left_10 Left_10 Left_11 Left_11 Right_6 Right_6 Right_7 Right_7 Right_8 Right_8 Right_9 Right_9 Right_10 Right_10 Right_11 Right_11 Left_12 Left_12 Left_13 Left_13 Left_14 Left_14 Medial Medial Lateral Lateral mm_3 mm_4 Right_12 Right_12 Right_13 Right_13 Right_14 Right_14 Medial_2 Medial_2 Lateral_2 Lateral_2 mm_5 mm_6 Hard Hard Soft Soft Hard_2 Hard_2 Soft_2 Soft_2 Toe Crest Left_15 Left_15 Left_16 Left_16 Left_17 Left_17 Left_18 Left_18 Left_19 Left_19 Right_15 Right_15 Right_16 Right_16 Right_17 Right_17 Right_18 Right_18 Right_19 Right_19 7 ADDITIONAL REQUESTS Subject Your message (optional)
