Westside Medical Supply
Eastside Medical Supply
765 Elmgrove Road
Rochester, NY 14624
Phone: (585) 227-8750
Fax: (585) 227-8563
PATIENT NAME:
DIAGNOSIS:
PHYSICIAN NAME:
PHYSICIAN SIGNATURE:
PHYSICIAN PHONE #:
ORTHOPEDIC ORDER FORM
FOOT
Forefoot offloading shoe *
Heel relief shoe *
All-purpose, post surgical shoe (open/closed toe)*
Extra depth shoes – (non-diabetic) Dr Comfort, etc.
Functional foot orthotics - Powerstep (L3040)*
Diabetic shoes-Dr. Comfort/Apis/PW Minor (A5500)
Diabetic shoe inserts, heat moldable (L5512)
Diabetic shoe inserts, custom (A5513)
Foot orthotics, custom (L3001-3020)
UCBL, custom (L3000)
Partial- foot insert custom (L5000)
Molded diabetic shoes, custom (A5501)
ANKLE
Elastic support *
Plantar fasciitis night splint (L4396) *
Ankle control orthosis, stirrup (Aircast) (L4350)*
Ankle gauntlet, prefab. (L1902)*
Multiligamentus support, prefab. (L1906)*
Walking boot (L4386)
Walking boot w/ pneumatic liner (L4360)*
Posterior leaf spring AFO, prefab. (L1930)*
Fillauer Dynamic Walk AFO, prefab.(L1951ORL1971)
Total carbon fiber AFO, prefab. (L1932)
Ossur Foot-up AFO (L1930)*
Solid ankle AFO, custom (L1960)
Posterior leaf spring AFO, custom (L1940)
Articulated AFO, custom (L1970)
Supramalleolar AFO, custom (SMO) (L1907)
‘Arizona’ style AFO, custom (L1940, L2820, L2330)
CROW orthosis, custom (L4631)
KNEE
2210 Monroe Ave.
Rochester, NY 14618
Phone: (585) 623-8936
Fax: (585) 623-8942
DOB:
/
/
NPI#:
DATE:
PHYSICIAN FAX #:
*Indicates in stock item
WRIST/HAND
Wrist support – neoprene or comp.*
Wrist/hand orthosis (cock-up splint) (L3908)*
Neoprene thumb support (L3911)*
Wrist/hand orthosis - thumb spica (L3807)*
Hand/finger orthosis - thumb spica, rigid (L3923)
Hand/finger orthosis - thumb spica, flex. (L3923)
Wrist/hand/finger orthosis, rigid, prefab. (L3807)*
European thumb spica (L3807)*
Wrist / hand / finger orthosis, jointed, custom (L3806)
Wrist/hand/finger orthosis, rigid, custom (L3808)
ELBOW
Tennis elbow gel band (L3701)*
Elbow orthosis prefab. neoprene or elastic (L3701)*
Elbow orthosis, adj. hinge OTS (L3760)*
Arm sling*
Shoulder brace (clavicle support) (L3660)*
Sling and swathe (L3670)*
Shoulder support (L3651)*
Dbl. upright elbow orthosis-custom, static (L3740)
Dbl. upright elbow orthosis-custom, dynamic (L3730)
SPINE
Cervical collar (soft) (L0120)*
Cervical collar (Miami J Adj. or Aspen Vista TX) (L0174)*
Abdominal (rib) support*
Posture control shoulder brace (L3650)*
Elastic lumbar sacral support (flexible)*
Light control LSO (L0625)*
Med. control LSO (L0626 &L0627)*
Max. control LSO (L0631or L0637)*clinical notes
Light control thoracic extension TLSO (L0456)
Medium control TLSO (chairback or comp.) (L0470)
Cruciform or Jewett lumbar ext.TLSO (L0472)
Rigid control custom TLSO, 1 piece (L0488)
Rigid control custom TLSO, 2 piece (L0486)
RENTAL PRODUCTS
Cryo/Cuff® Ice Cooler & Sleeve*
LaserTouchOne*
Lateral J patellar stabilizer*
Open patella sleeve w/stays*
Elastic or neoprene knee sleeve*
Patella support *
Hinged neoprene knee orthosis (L1810)*
Hinged neoprene knee orthoses, padded (L1820)*
O/A single upright knee orthosis prefab. (L1843)
REQUEST OTHER
Adjustable hinged ROM knee orthosis (L1832)*
Knee orthosis, dbl. uprt, OTS, funct/ O/A (L1845)
 Form may be brought in, mailed, or faxed to:
Knee orthosis, dbl. upright, custom (L1846)
Westside Location @ (585) 227-8563
Dbl. upright KAFO, custom (L2036)
OR Eastside Location @ (585) 623-8942