Apis Footwear CUSTOM-MOLDED SHOE ORDER FORM Apis Footwear Company East

2239 Tyler Ave. 6900 Riverport Drive, Unit C

South El Monte, CA 91733 Tel: (888) 937-2747 Fax: (888) 990-2245 Email: Orders@ApisFootwear.com Louisville, KY 40258
Fill form out completely, and include a weight bearing tracing in order to guarantee fit
Purchase Order No. Ship Via: Ground Next Day 2nd Day 3rd Day
Prac��oner Ship To
Account No. Address
Bill to Address
Phone Fax City State Zip

PATIENT INFORMATION SHOE DESIGN

Name: _______________________________________ Shoe Style (from catalog): __________________ Color_________

Sex: Male Female Shoe Size & Width (if not custom): L ________ R________
Weight _______________ Height ________________ Closure: Laces D Ring Hook & Loop
Reverse D-ring Hook & Loop: L R
Diagnosis (Please check the box that applies) Opening: Regular Semi-Surgical Surgical
Diabetes Amputated Toes L R Lining: So� Cloth Plastazote®
Neuropathy Hammer Toes L R Mesh Leather
Tongue: No Padding Extra Padding
FOOT MEASUREMENT Collar: No Padding Extra Padding Lycra
Soling: Light Weight Rigid Heavy Duty
Foot Measurement Circumferences
Foot Length: L_____ R_____ Ball: L_____ R_____
EXTERNAL SOLE MODIFICATION
Ball Width: L_____ R_____ Instep: L_____ R_____
Toe Height: L_____ R_____ Heel: L_____ R_____
Forefoot Rocker L R
Ankle: L_____ R_____ Mild Rocker L R
(Standard elongation of 5/8” is added if no specific length is given) Heel-to-Toe Rocker L R
Toe Elonga�on: L_____ R______ Severe Angle Rocker L R
Extra Toe Box Height: L_____ R______ or (1/4”) Double Rocker L R
Shoe/Boot Height (not Including outsole): L ______ R_______ Rocker Bar L R
Match Shoe to Length: Nega�ve Heel Rocker L R
LOP Rocker L R
CUSTOM INSERTS SPECIFICATIONS 3/4 Steel Shank L R
Quan�ty: L_____ R______ Full Length Steel Shank L R
Bevel Heel L R
Material: Tri-lam (Plastazote® + PPT + EVA)
SACH Heel L R
Op�onal Top Covers: Spenco Leather
Snug Heel L R
Op�onal Bases: EVA Cork Cork Composite Toe Box L R
Base Density: So� Medium Hard Reinforce Heel Counter L R
Heel Cup: Flat Medium Deep Detached Sole L R
Medial Flange: L R Medial Post: L ____ R_____ Lateral Sole Flare L ______ R ______
Lateral Flange: L R Lateral Post: L ____ R _____ Lateral Bu�ress L ______ R ______
Met Pad: L R Arch Pad: L R Lateral Sole Wedge L ______ R ______
Medial Sole Flare L ______ R ______
Toe Fillers: Le� 1 2 3 4 5 Medial Bu�ress L ______ R ______
Medial Sole Wedge L ______ R ______
Right 1 2 3 4 5
Build-Ups (Li�) (Buildups are placed on outsole unless box is check)
Heel L _______ R_______ Li� inside shoe
Ball L _______ R_______
Toe L _______ R_______
Right Le�
Foot Foot Special Instruc�ons: (Please Print Clearly)
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
Mark prominent areas for off-loading ____________________________________________________
____________________________________________________