SureFit Custom Insert Order Form
This file is a SureFit Custom Insert Order Form designed to provide the necessary details and instructions for ordering custom inserts. Users can specify measurements, accommodations, and other relevant information. The form ensures correct fit and comfort for custom-made footwear inserts.
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How do I fill this out?
To fill out the SureFit Custom Insert Order Form, begin by entering the practitioner's contact details and patient information. Specify the style, length, and width of the inserts before providing measurements and any required accommodations. Ensure all necessary fields are complete to avoid delays.
How to fill out the SureFit Custom Insert Order Form?
1
Enter the practitioner's contact details and patient information.
2
Specify the style, length, and width of the inserts.
3
Provide foot measurements and accommodations, if needed.
4
Indicate the quantity and type of inserts required.
5
Submit the completed form with any additional instructions.
Who needs the SureFit Custom Insert Order Form?
1
Podiatrists needing to order custom inserts for their patients.
2
Patients requiring special accommodations for their footwear.
3
Orthopedic clinics managing large orders of custom inserts.
4
Athletes looking for specially designed shoe inserts for better performance.
5
Individuals with specific foot-related issues needing custom-made solutions.
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1
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2
Use the PDF editor to fill in all necessary fields.
3
Add or modify text, annotations, and signatures as needed.
4
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5
Download or share the completed form.
What are the instructions for submitting this form?
To submit the SureFit Custom Insert Order Form, ensure all fields are filled out accurately. Include all necessary foot measurements, accommodations, and special instructions. Submit via fax to 888.801.3450 or mail to SureFit, 4050 NW 126th Ave, #110, Coral Springs, FL 33065. For additional support, contact SureFit at 800.298.6050.
What are the important dates for this form in 2024 and 2025?
There are no specific important dates associated with the SureFit Custom Insert Order Form for 2024 and 2025.
What is the purpose of this form?
The SureFit Custom Insert Order Form is designed to assist practitioners and patients in ordering custom-made footwear inserts. By providing detailed information on measurements, accommodations, and specific patient needs, the form ensures that ordered inserts fit correctly and offer maximum comfort. Filling out this form accurately helps streamline the order process and reduces the need for adjustments.
Tell me about this form and its components and fields line-by-line.
- 1. SureFit/SPS Acct Number: Unique identifier for the practitioner's account.
- 2. Date: Date the order form is being filled out.
- 3. Contact/Practitioner Name: Name of the contact person or practitioner filling out the form.
- 4. TEL: Telephone number for contact purposes.
- 5. FAX: Fax number for sending the order form.
- 6. Patient ID: Identifier for the patient receiving the custom inserts.
- 7. Gender: Gender of the patient, indicated as male or female.
- 8. Brand: Brand of the inserts being ordered.
- 9. Style (model#): Specific style or model number of the insert.
- 10. Length: Length of the insert.
- 11. Width: Width of the insert.
- 12. Custom Insert Order Information: Details on whether inserts only or both shoes and inserts are ordered.
- 13. Foot Measurements: Measurements including Heel to Toe, Heel to Ball (arch length), Width, and Semi-Circumference.
- 14. Current Shoe and Fit: Information on the current shoe and fit for both left and right foot.
- 15. Accommodations: Details on required accommodations with an option for lab to determine accommodations.
- 16. Notes/Special Instructions: Any specific notes or instructions related to the order.
- 17. Quantity: Quantity of inserts required for both left and right foot.
- 18. Missing Toes: Details on any missing toes for both left and right foot.
- 19. Relief (cut out): Details on relief (cut out) as marked on imprint.
- 20. Heel Lift: Details on heel lift either in shoe or on insert.
- 21. Wedge on Insert: Details on lateral or medial wedge on insert.
- 22. Wedge in Shoe: Details on lateral or medial wedge in shoe.
What happens if I fail to submit this form?
Failure to submit the form correctly can lead to delays and additional adjustments.
- Incorrect Insert Size: Inserts will be made longer and wider for in-clinic adjustments.
- Order Processing Delays: Incomplete or incorrect information may cause delays in processing the order.
- Patient Discomfort: Incorrectly fitting inserts can lead to patient discomfort and may require further modifications.
How do I know when to use this form?
- 1. Podiatrist Orders: When a podiatrist needs to specify custom inserts for a patient.
- 2. Orthopedic Clinics: For clinics managing large orders of custom inserts.
- 3. Patient Requests: When a patient requires custom-made inserts for specific foot conditions.
- 4. Athletic Needs: For athletes requiring specially designed shoe inserts.
- 5. Foot-Related Issues: When individuals need custom solutions for foot-related problems.
Frequently Asked Question
How do I start filling out the form?
Open the document in PrintFriendly’s PDF editor and begin by filling in the practitioner's contact details and patient information.
Can I make changes after completing the form?
Yes, you can use PrintFriendly’s PDF editor to modify text, annotations, and other details even after the initial completion.
How do I add foot measurements?
Enter the foot measurements in the designated sections for heel-to-toe, heel-to-ball, width, and semi-circumference.
Can I specify accommodations for the inserts?
Yes, you can indicate accommodations by circling the respective areas on the INK IMPRINT/PRESSURE STAT or letting the lab determine them.
Is it possible to order both shoes and inserts?
Yes, you can specify if you need inserts only or shoes and inserts by selecting the appropriate option on the form.
How do I sign the form?
Use PrintFriendly’s PDF editor to add your digital signature to the form.
Can I share the completed form?
Yes, PrintFriendly allows you to share the completed form via a shareable link or by sending it through email.
How do I submit the form?
Complete the form with all necessary details and accommodations, then submit it by mailing to the provided address or sending via fax.
What happens if the form is not completed correctly?
If the form is incomplete, inserts will be made longer and wider for in-clinic adjustments.
Can I save a copy of the form for my records?
After editing and filling out the form, you can download a copy for your records using PrintFriendly.
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