Referral Pad Servicing and Bracing "*" indicates required fields Referring Doctor* Patient Name* Patient Contact Number* Date* Condition*WALKERS, SHOES, SPLINTS AND BRACES Full Shell Walker Short Air Walker Darco Post-Op Shoe Darco Orthowedge Sandal Darco Diabetic Offloading Shoe Bunion Splint - Fixed Bunion Splint - Rom Plantarfasciitis Splint Aircast Stirrup Brace TriLok Ankle Brace Aircast PTTD Brace & Ankle Brace Richie Brace Richie Brace Standard Richie Brace Arch Suspender Richie Brace Dynamic Assist Richie Brace Restricted Hinge Standard - Indication: PTTD mild-moderate; Lateral ankle instability; Peroneal Tendinopathy; Cavo-varus deformity Arch Suspender - Indication: PTTD mildmoderate; Lateral ankle instability Dynamic Assist - Indication: Drop Foot; Peroneal Nerve Injury, Post CVA Restricted Hinge - Indication: PTTD moderate – severe; Dropfoot; DJD ankle; Peroneal Tendinopthy; Lateral ankle stability (severe); Peroneal nerve injury with fixed varus hindfootOther Heel Cups/Cushions Anodyne Medical Grade Footwear Further ranges of Foot and Ankle orthotic bracing available including Vacoped, Aircast and more. Contact us today to discuss your individual requirements.ORTHOTICS Custom Made Orthotic PreFabricated Orthotic Orthotics UCBL Gecko Children’s Orthotic Material EVA -Single density EVA -Dual density EVA -Tri density Polypropylene Carbon fibre Length Full Length Device 3/4 Device To Sulcus Type Corrective Accomodative Orthotic Additions Met Domes Met Bars IPK Pads Dancers’ Pads Morton’s Extension - EVA: 1st Ray Morton’s Extension - Polypropylene: 1st Ray Morton’s Extension - Carbon Fibre Hallux Rigidus Plate Anti-sheer top cover (diabetic/RA) Slow Recovery Cushioning Heel Raise - 3mm Heel Raise - 4mm Heel Raise - 5mm Heel Raise - Other TREATMENT REQUESTS/SERVICES Pre and Post-Surgical Care Oedema Management – Intermittent pneumatic compression device Pain Management – Interferential, Extracorporeal Shockwave Therapy SWIFT therapy – Verrucae treatment Rehabilitation – Exercise programs Wound care – Diabetic, Ischaemic, Neuropathic, Trauma, Post-surgical Footwear Assessment and Prescription General Foot Care – nails, corns, callous Orthotic Therapy Nail Bracing – Reduction of nail involution and treatment of ingrowing nails Children’s Foot Health and Orthotic Therapy Non-invasive Nail Surgery – with and without phenolisation Diabetes Risk Assessments – ABI, TBI, Doppler, PPG, Neurological Assessments Please provide further details regarding products or services you would like us to provide to your patient:We strive to keep you informed about your patients’ progress. Please select your preferred communication type: Medical Objects Efax Email
