Patient Name: _____________________________________________________________________________________
Patient DOB: ______________________________________________________________________________________
Included with Custom-Made Foot Orthotic submission:
- Itemized paid receipt (including date)
- Biomechanical assessment/gait assessment
- Referral/prescription
- Lab invoice or packing slip or *A copy of orthotic lab order if the dispenser is also the manufacturer
1) Assessment and Dispensing
1. Date of Assessment: ____________________________________________________________________________
2. Date of Dispensing/Fitting: _______________________________________________________________________
2) Design & Manufacturing
Foot Capture Technique (casting/scanning technique(s) used to create a negative cast):
- Direct Mold Using Raw Materials
- Foam Box Impression
- Plaster Slipper Cast
- Polyester or Fiberglass Resin Casting Sock
- Wax Mold
- Other (please describe): ________________________________
3) Practitioner Qualification
Professional Qualifications: __________________________________________________________________________
College Registration Number: ________________________________________________________________________
Date: _____________________________________________________________________________________________
Canadian Certified Pedorthist Name: _________________________________________________________________
Signature: _________________________________________________________________________________________
For more information, contact The Pedorthic Association of Canada at 1-888-268-4404 info@pedorthic.ca / www.pedorthic.ca