Apis Footwear CUSTOM-MOLDED SHOE ORDER FORM Apis Footwear Company East 2239 Tyler Ave. 6900 Riverport Drive, Unit C Tel: (888) 937-2747 Fax: (888) 990-2245 Email: [email protected] South El Monte, CA 91733 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 INF ORMATION SHOE DE SIGN

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 Material: Tri-lam (Plastazote® + PPT + EVA) Bevel Heel L R SACH Heel Op�onal Top Covers: Spenco Leather L R 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 ______Right 1 2 3 4 5 Medial Sole Wedge L ______R ______Build-Ups (Li�) (Buildups are pla ced 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 ______