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CLINIC PORTAL
Home
About
Services
Contact
CLINIC PORTAL
UCBL
UCBL
Step
1
of
4
25%
Order Details
Clinician
*
Contact Phone
Contact Email
*
Due Date
*
Standard Turn Around
Rush Order (additional charges may apply)
Date Required
MM slash DD slash YYYY
We will do our best to meet your deadline!
Patient Details
Patient name/ID
*
Patient Weight (kg)
*
Patient Height (cm)
*
Model Details
Side
*
Left
Right
Bilateral
Model Details
*
I am providing a MODIFIED scan
I am providing an UNMODIFIED scan
I am posting a negative cast
I am posting a modified plaster model
Scan File
Accepted file types: stl, cvx, o01, obj, ply, vsrf, Max. file size: 2 MB.
We will accept scans in the following formats: .stl .cvx .o01 .obj .vsrf .ply
Orthosis Detail
Foot Style
*
Full Length
Sulcus Length
3/4 Length
Stirrup/heel only
Encapsulate Met Heads
*
None
First MH Only
Fifth MH only
Both First and Fifth MH
Foot Length (cm)
*
measured from back of heel
Transfer Paper Colour
No Transfer
Ice Age
No Dogs
1 of 100 others...
Plantar Padding
*
None
2mm EVA Foam
Additional Spot Padding
No
Yes
3mm EVA Foam
Spot Pad
Cast Corrections
Corrections Are:
Identical Left and Right
Different Left and Right
Are the cast corrections the same on each side?
Anglular Cast Corrections
Please carefully review your selection
Left Side Anglular Cast Corrections
Please carefully review your selection
Left Ankle Angle
*
Neutral/Plantigrade (SVA 5deg)
As Cast/Scanned
Dorsiflexion
Plantarflexion
Ankle Angle (degrees)
Left Calcaneal Angle
*
Neutral
As Cast/Scanned
Eversion
Inversion
Calcaneal Angle (degrees)
Left Side Forefoot Corrections
Left Forefoot Offset
*
Neutral
As Cast/Scanned
Abducted
Adducted
Forefoot Offset (degrees)
Left Forefoot Rotation
*
Neutral
As Cast/Scanned
Inverted
Everted
Forefoot Rotation (degrees)
Malleolar M-L (mm)
MetHead M-L (mm)
Trim Length (mm)
Right Side Angular Cast Corrections
Right Ankle Angle
*
Neutral/Plantigrade (SVA 5deg)
As Cast/Scanned
Dorsiflexion
Plantarflexion
Right Ankle Angle (degrees)
Right Calcaneal Angle
*
Neutral
As Cast/Scanned
Eversion
Inversion
Right Calcaneal Angle (degrees)
Right Side Forefoot Corrections
Right Forefoot Offset
*
Neutral
As Cast/Scanned
Abducted
Adducted
2nd Forefoot Offset (degrees)
Right Forefoot Rotation
*
Neutral
As Cast/Scanned
Inverted
Everted
Right Forefoot Rotation (degrees)
Malleolar M-L (mm)
MetHead M-L (mm)
Trim Length (mm)
Additional Notes
