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Custommade Ordering Form
(Supreme /Wedges)
Existing Patient
Patient Details
Mobile Number:
(or) Patient ID:
Search
Your Patient ID:
Your Name:
Name of the Patient
*
Mobile Number
*
Age
*
Gender
*
Male
Female
Shipping Address
*
Pin code
*
Submit
Product Selection (Maximum 3 products allowed)
Supreme (Pair)
₹
2500
Qty
Color
Black
Brown
Anterior Wedges (Pair)
₹
2200
Qty:
Posterior Wedges (Pair)
₹
2200
Qty:
Anterior Offloader (Pair)
₹
3450
Qty:
Side:
Left
Right
Posterior Offloader (Pair)
₹
3450
Qty:
Side:
Left
Right
Please proceed with your measurement and photo upload
Left Foot
Length of the Foot (A CM)
*
Width of the Foot (B CM)
*
Right Foot
Length of the Foot (A CM)
*
Width of the Foot (B CM)
*
How to Measure Foot Length & width
Left Foot
Forefoot Circumference (A CM)
*
Midfoot Circumference (B CM)
*
Right Foot
Forefoot Circumference (A CM)
*
Midfoot Circumference (B CM)
*
How to Measure Forefoot Circumference
Sample Picture
Upload Anterior Side Photo (Both)
*
Upload Posterior Side Photo (Both)
*
How to Measure Midfoot Circumference
Do you need an arch support in the footwear (Both)?
*
Yes
No
Select
15MM
20MM
25MM
Left Foot
Do you have Ulcer in the Foot?
*
Yes
No
Bottom of Foot Image (ulcer)
*
Right Foot
Do you have Ulcer in the Foot?
*
Yes
No
Bottom of Foot Image (ulcer)
*
How to measure ulcer size
Any Additional Notes
*
Product
Color / Side
Correction
Qty
Total
Grand Total
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