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Semi-Custommade Ordering Form (Supreme /Wedges)
Patient Details
Name of the Patient
*
Mobile Number
*
Age
*
Gender
*
Male
Female
Shipping Address
Pin code
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
Product
Color / Side
Correction
Qty
Total
Foot Measurement
Left Foot
Length of the Left Foot (A)(CM)
Width of the Left Foot (B)(CM)
Upload Anterior Side Photo (Both)
Right Foot
Length of the Right Foot (A) (CM)
Width of the Right Foot (B) (CM)
Upload Posterior Side Photo (Both)
Do you need an arch support in the footwear (Both)?
Yes
No
Select
15MM
20MM
25MM
Do you have Ulcer in Left?
Yes
No
Ulcer Image in Left
*
Do you have Ulcer in Right?
Yes
No
Ulcer Image in Right
*
Any Additional Notes
Submit