Prescriber Name *

Prescriber Profession *

Clinic / Business Name *

Email Address *

Patient Reference *

Helper text: Use your own clinic reference, patient initials + birth year, or any code from your practice system. This is used only to identify the orthotic on delivery.

Patient Email Address

This helps generate actionable data we can feed back to you and your clinic / business

Capture Method *

Add Image and/or Pressure Data of Patient's Feet / Foot

Increase the placement accuracy of your orthotic modifications

Shoe Size (UK) *

Last Shape *

Patient Name

(optional — printed on your orthotic)

Primary Diagnosis *

Secondary Diagnosis

Is this a high-risk or diabetic foot?

Prescribe By

This Prescription Applies To *

Select "Mirror both feet" if both orthotics are identical. Select "Design both feet separately" if each foot requires different specifications.

Orthotic Shell Material

Arch Height

Shell Length

Heel Cup Depth

Shell Width

Shell Thickness

Measured at heel and forefoot, 2mm standard.

Cast Correction to Neutral

Yes

Forefoot Bevel

Yes

Midlayer

3mm thickness as standard unless requested otherwise

Top Cover

Ceramic and synthetic leather only available in low and standard heel cup depths

Cover Length

Patient & Clinic Reported Outcomes

Please take 60 seconds to answer the below questions. This will allow us to return outcome measure data specific to your clinic back to you as well as improving our service.

Patient's Primary Complaint (subjective)

Patient's subjective complaint

Symptom Duration

VAS Score

Main Activity Limited by Complaint

Patient's Main Treatment Goal

Primary Use of Orthotics

Activity Level

Previous Orthotic Use

Yes

Clinical / Additional Notes

RehabHub3D - Exercise Rehabilitation

RehabHub3D pairs structured exercise rehabilitation with your orthotic prescription. Clinics using both report improved patient outcomes and higher satisfaction scores.

Are you a RehabHub 3D User?

Yes, I have an account

No, not interested

No, but I'd like to find out more

Have you Directed Your Patient Into one of our Affiliate 'Return to...' Partners?