3D Printed FO
FO 3D
Please Select
FO 3D
Patient Name
*
First Initial
Last Name
Encounter # / PO #
*
Practitioner
*
Clinic Location
*
Please Select
Big Rapids (781800)
Bloomington (317000)
Byron Center, MI (781900)
Carmel (317100)
Charlotte (318500)
Charlotte (477800)
Columbus (317200)
Danville (317700)
Evansville (317300)
Fort Wayne (006100)
Grand Rapids (772700)
Greenwood (317400)
Greenville (786900)
Holland (016800)
Indianapolis (317500)
Indianapolis (780600)
Indianapolis (780800)
Kalamazoo (780300)
Kokomo (785700)
Lexington (317800)
Lexington (007900)
London (317900)
Louisville I (318000)
Louisville II (318100)
Louisville III (008100)
Louisville IV (472000)
Marquette (787400)
Monroe (318700)
Mooresville (318800)
Morehead (318200)
Mt. Sterling (318300)
Paducah (000100)
Paducah (318400)
Petoskey (787700)
Seymour (317600)
Somerset (028100)
South Bend (765100)
Support Center (318900)
Tamarac (021000)
Other (Approval Required)
Email
*
Please enter to receive confirmation.
Today's Date
-
Month
-
Day
Year
Date
Due Date
-
Month
-
Day
Year
Date
Back
Next
3D Printed FO
Patient Information
Weight
Age
*
Diagnosis
Shoe Size
*
Include Width if applicable
Gender
*
Male
Female
Affected Side
*
Left
Right
Bilateral
Affected Side Container
Scan acquired using iPHONE and COMB app WITH the Scanning Mirror
*
Yes
No
Scan Upload
Browse Files
Drag and drop files here
Choose a file
Please Include a picture of the current insert along with a reference item for scaling.
Cancel
of
Insert Image Not available
FO Profiles
*
Device Type
*
Functional (Firm)
Accommodative (Soft)
Extra Accommodative
Back
Next
3D Printed FO
Modifications to Scan
Met Pad
Left
Mild
Moderate
Strong
Right
Mild
Moderate
Strong
Insert Posting
Left
Medial
Lateral
Right
Medial
Lateral
Left Posting
*
Full
Heel
Forefoot
Right Posting
*
Full
Heel
Forefoot
Left Posting1
Full
Heel
Forefoot
Right Posting1
Full
Heel
Forefoot
Heel Cushion
Left
Right
Heel Cup
Depth
*
Shallow
Normal
Deep
Toe Filler/Partial Foot
Left
Right
Back
Next
3D Printed FO
Modifications to Scan
Reliefs
Mark on Diagram
Right
Left
Draw on Image
Back
Next
3D Printed FO
Top Cover
1/8"
Single Lam
Bi-Lam (Puff/P-Cell + Poron)
1/8" Single Lam
*
Blue Puff
Pink Camo Puff
Black Puff
Black Ice
P-Cell (Pink)
Lab's Choice
No Top Cover (Built to scan, i.e. no room for applying top cover)
Will apply Top Cover in Office
1/8 " Bilam
*
1/16 Blue Puff + 1/16 Poron
1/16 Black Puff + 1/16 Poron
1/16 Pink Camo Puff + 1/16 Poron
1/16 Black Ice Puff + 1/16 Poron
1/16 Pink P-Cell + 1/16 Poron
Lab's Choice
No Top Cover (Built to scan, i.e. no room for applying top cover)
Will apply Top Cover in Office
Top Cover Thickness
*
Will be used to allow room for the Top Cover
Notes
Submit
Should be Empty: