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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 foot (B)(CM)
Width of the foot (A)(CM)
Upload Anterior Side Photo
Right Foot
Length (CM)
Width (CM)
Upload Posterior Side Photo
Do you need arch support in the footwear?
Yes
No
Select
15MM
20MM
25MM
Do you have Ulcer?
Yes
No
Ulcer Image
*
Do you have Ulcer?
Yes
No
Ulcer Image
*
Submit