Advanced Orthotic Prescription – Dola Direct

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Advanced Orthotic Prescription

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Step 1 of 8 - PATIENT DETAILS

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Product Name
Tell us about your patient and we will design, customise and send you the orthotic you need.
Date
Date Format: MM slash DD slash YYYY
Patient Name / Identifier
First Last

Please take at least 2 photos to help with getting the best result. You can also attach additional clinical photos as required
Anterior
Posterior
Upload Photos
Drop files here or

Accepted file types: jpg.

Select the orthotic type & size for your patient
Size (US)*
Click here for sizechart
Select the orthotic style(s) for your patient*
- Pro - Full Length
- Pro - 3/4 Length
- Pro - Lite
- Pro - Fit

Please select your patients foot type
- Pronated
- Neutral
- Supinated
Choose the Level

General
- Comfort
- Prevention
- Performance
Lower Back/Hip
- SIJ
- Sciatica
Leg/Knee
- Anterior: PFJ/Patella
- Lateral: ITB/LCL/Joint
- Medial: Adductor/MCL/Joint
Lower Limb/Ankle
- Achilles Tendonopathy
- Ankle Equinus
- Anterior Impingement Syndrome
- Flexor Hallucis Pathology
- Gastroc/soleus Pathology
- Lateral Ankle Sprains
- Peroneal Tendon Pathology
- Shin Splints: Anterior
- Shin Splints: Posterior
- Tibialis Anterior Pathology
Rearfoot
- Chronic Plantar Heel Pain: Plantar fasciitis
- Fat Pad Syndrome
- Peroneal Pathology
- Plantar Calcaneal Bursitis
- Retrocalcaneal Bursitis
- Tarsal Tunnel Syndrome
- Tibialis Posterior Pathology
Midfoot
- Cuboid Syndrome
- Lisfranc Injury
- Midtarsal Joint Sprain
- Navicular Pathology
- Plantar Fascia Pathology
Forefoot
- 1st MPJ Injury
- 5th Metatarsal Injury
- Corns/Callus
- Friebergs Osteochondritis
- Functional Hallux Limitus
- Hallux Rigidus
- HAV (Bunions)
- Metatarsal Stress Fracture
- Metatarsalgia (Capsulitis / Bursitis)
- Neuroma: Interdigital Neuritis
- Plantar Plate Injury
- Sesamoid Injury
Kids
- Flat Feet
- Osgood Schlatters
- Sinding - Larsen
- Calcaneal Apophysitis: Severs Disease
- Paediatric Out-toeing
- Paediatric In-toeing
- Paediatric Toe Walking

Please add results of your clinical tests, if performed.
Range of Motion - Non Weight Bearing
Ankle
- >10°
- <10°
Subtalar Joint (STJ) Inversion
- >20°
- <20°
Subtalar Joint (STJ) Eversion
- >10°
- <10°
Midtarsal Joint (MTJ)
- Mobile
- Restricted
1st Metatarsophalangeal Joint (1st MPJ)
- >65°
- 20° - 65°
- <20°
Resting Stance Position
Calcaneus Position
- Everted (pronated)
- Vertical
- Inverted (supinated)
Arch Height
- Low
- Normal
- High
MSRT Force
- Low
- Moderate
- High
Sagittal Plane Assessment
Lunge Test
- > 10cm
- < 10cm
Jacks Test Force
- Low
- High
Jacks Test Range
- Low
- High

Important considerations when choosing the best top cover for your patient include:

Special needs including cushioning, high risk, diabetic

Space available / type of footwear

Daily general activity / sports / high impact
Durafit
- Black (Smooth)
- Bronze (Smooth)
- Cocoa (Smooth)
- Skin (Smooth)
- Anthracite (Semi Perforated)
- Beige (Semi Perforated)
- Black (Semi Perforated)
- Blue (Semi Perforated)
- Camel (Semi Perforated)
- Cream (Semi Perforated)
- Lime (Semi Perforated)
- Magenta (Semi Perforated)
- Marine/Navy (Semi Perforated)
- Orange (Semi Perforated)
- Silver (Semi Perforated)
- Skin (Semi Perforated)
- Stone (Semi Perforated)
EVA
- Black
- Black/Grey
- Blue
- Blue Swirl
- Lime Green
- Lime Swirl
- Natural
- Pink
- Pink Swirl
- Purple
- Red
- Yellow
High Risk / Diabetic
- Diabetic Anti Shear
- Diabetic Anti Shear 100kg+

Use for additional information including patient assessments, orthotic prescription, custom padding, diabetic offloading and footwear
Notes (Optional)
Name
This field is for validation purposes and should be left unchanged.

Advanced Orthotic Prescription quantity

Category: Orthotics

Description

WHAT YOU RECEIVE

ASSESSMENT

Our Australian Foot Doctors will join you to provide your patients with a solution for their foot and leg problems

ORTHOTIC INSOLES

Your patients prescription Orthotic insoles will be designed and made specifically for them

EXERCISE PROGRAM

Your patients home based rehabilitation and physical therapy program

FREE ROLLER

Included DOLA massage roller for pain relief and rapid healing

FREE RESISTANCE BAND

Build a stronger and flexible body for injury prevention and improved performance

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FREE DELIVERY
WHAT YOU RECEIVE
RETURNS & REFUNDS

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