The Stabilizer Prescription Form
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65 PLAIN AVENUE
NEW ROCHELLE, NY 10801
914-235-9100 • FAX: 914-235-9697
800-473-6682
ortho-rite.com
FOR LAB USE ONLY
 
 
ACCOUNT# LOG #
 
SI   SO   INV.

The Stabilizer

OFFICE NAME   DATE 
DOCTOR *   PHONE# * 
ADDRESS *   EMAIL * 
PATIENT NAME *   SEX  AGE  WEIGHT 
SHOE SIZE   TYPE WORN  OCCUPATION 
DIAGNOSIS AND
OBSERVATIONS
CAST TAKEN   NON WEIGHT BEARING  
SEMI WEIGHT BEARING   WEIGHT BEARING  

BRACE
 
RIGHT LEFT BILATERAL
 
POST SPECIFICATIONS
 
REARFOOT
EXTRINSIC INTRINSIC
Post According To Lab Evaluation
0 degrees 3 degrees 5 degrees
 
FOREFOOT EXTRINSIC
Post According To Lab Evaluation
0 degrees 3 degrees 5 degrees
 
HEEL CUP DEPTH
10 mm 15 mm 35 mm(standard)
 
REQUIRED MEASUREMENTS
A) Width of Forefoot at the Metatarsal Heads
inches 
B) Width of Ankle Joint at the Widest Point
inches 
C) Circumference above the ankle
inches 
D) Circumference at 3" above the ankle
inches 
 
LAB CAST CORRECTION FEE*
To avoid additional charges, we suggest casts be
taken With the ankle at 90o
Neutral and the Foot in Subtalar Neutral
 
SPECIAL INSTRUCTIONS
NO CHARGE OPTIONS
 
REPLACE STANDARD TOP COVER WITH:
  3/16" PPT PLASTAZOTE 1/8" SPENCO
  3/16" MULTI-COLOR MEDIUM DENSITY EVA TOP COVER
ADD FIRST RAY CUTOUT
 
 
 
FOR AN ADDITIONAL CHARGE
PPT ARCH FILL
TEMPORARY 90 DEGREE ANKLE LOOK
ADDITIONAL MEDIAL/LATERAL INTERFACE PADS
PPT GEL COLD THERAPY INSERTS
 
 
STANDARD SPECIFICATIONS
  • CUSTOM MOLDED POLYPROPYLENE FOOT ORTHOSES
  • FREE MOTION ANKLE JOINT ATTACHED TO A UNIQUE POLYPROPYLENE INTEGRATED ON PIECE CALF DESIGN
  • 35 MM DEEP HEEL CUP
  • REMOVABLE MEDICAL AND LATERAL INTERFACE PAD
  • BALANCED BIODYNAMIC FOREFOOT AND REARFOOT SYSTEM
  • STANDARD MET LENGTH SHELL WITH COMPRESSIBLE POST TO SULCUS
  • VELCRO®CLOSURE
  • PPT®ULTRALUX®PADDED TOP COVER TO SULCUS
 
 
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© 2006 Ortho-Rite, Inc.
65 Plain Ave. • New Rochelle, NY 10801
(800) 473-6682 • (914) 235-9100 • Fax (914) 235-9697 • info@ortho-rite.com