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1-877-524-0639

 

 

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"The Best Fitting Shoes on Earth"
 www.branier.com
 

527 Pomegranate Ave.  • Sebring, FL 33870
Phone: (877) 524-0639 • Fax: (863) 314-0083
 

COMPANY NAME:

Phone: Fax:
P.O.#    Ordered by:
Email:

SHIP TO NAME:

Address:

City:    State:   Zip:

BILL TO NAME:

Address:

City:   State:   Zip:

Patient Name:

Address:

City:   State:   Zip:
Sex:             Weight:        Age:

Occupation:

Had Branier Shoes Before (approx. date):

DIAGNOSIS

L

R
Diabetic:
Post Polio:
Amputee:
Charcot:
Club Foot:



Toes..


Arch..

 Overlapped:
Hammered:
No Deformity:
Flexible Deformity:
Rigid Deformity:









Arthritic Other:

Style #   Color:
An "A" following the Style Number indicates velcro closure.

Regular Opening:
Semi-Surgical:
Surgical:

Other:

SHORT LEG BUILD-UP

All buildups are placed on outsole.  Check here for inside

 

L

R

Heel*. . . . . . . .
Ball*. . . . . . . . .
Toe*. . . . . . . . .

Inch
Inch
Inch

 Inch
Inch
Inch

Other: 

SOLE MODIFICATIONS

 

L

R

Lateral Heel Flare*
Lateral Sole Flare*
Medial Heel Wedge*
Medial Sole Wedge*
Lateral Heel Wedge*
Lateral Sole Wedge*
Medial Heel Flare*
Medial Sole Flare*
Wide Base*
Reinforced for Brace*





















Other:

CONSTRUCTION





Regular (light)          Celastic Counters (standard)
Heavy Duty Leather (Black, Brown, Cedar)*

Reinforced (double) Extended Counters*
Full Leather Slip sole (welted construction)*

EXTERNAL ADDITIONS

L

R

To Match (length)
Short
Steel Shank*
⅞" Caliper Plate*
Base Depressions*







Other:

UPPERS

L

R

Velcro D-Ring Normal Direction (standard)
Velcro D-Ring Reverse Direction
Velcro Flap Normal Direction
Velcro Flap Reverse Direction








T-Strap*     Hooks    Lace    Speed Lace*
Tongue (no padding)   Collar (no padding)
(Collar and Tongue come padded standard unless otherwise noted)

Other:

 

CAST MODIFICATION

Reg. Elongation (⅝"):
High Toe Box:
Duplicate Cast*          



 ⅛" Extra (⅝" + ⅛"):
 Extra High Toe Box:
 6 Day Rush*

Other:

Please indicate No# or Letter from picture of your problem area with details, below.

                     Indicate Problem Areas by No# and Letters Above.

Details of Problem:

¼" Pink + ¼" White (standard)
¼ Pink + ⅛ Poron® + ¼ white*
Poron® Cover*
Spenco® Cover*
Leather Cover*



½" White (firm)
¼" White (firm)
½" Pink (soft)
¼" Pink (soft)


Cosmetic Toe Filler* . . . . . . . . . .
Total Contact Toe Filler*. . . . . . . 
Other: . . . . . . . . . . . . . . . . . . . . . .

LINING
B-Foam Cushion (standard)
Full Leather



 

Plastazote® Full Lined* Vamp Only*  Heel Only*
Other . . . . . . . . . . . . . . . . . . . . . . .

SOLING

 

LW (12 I)    Reg. (18 I) Heavy Duty (24 Iron)
Heavy Duty Ribbed Soling*
Other:
(Rocker Soles come standard unless otherwise noted.)

CREATE A PACKAGE
(not available on single shoe orders)

1.

  Style #

2.
3.


 Velcro
 Black
 Navy
 Brown		 Lace
White
Cordovan
Dark Brown
Bone
Luggage Tan
Other
Taupe
 4 The standard package comes with two additional pairs of custom inserts.  You may create a customized package by substituting one pair of inserts for one modification below or substitute two pairs of inserts for two modifications below.  Please note that left and right options count as one substitution each.

Substitutions 1           2
 5 Options
 









 




 

  Third Layer on Insoles
Any combination of two materials other than standard
¼" Pink & ¼" White Plastazote®
Heavy Duty Ribbed Soling
Toe or Forefoot Filler (1)  L     R
Full Steel Shank (1)  L      R
Plastazote® Lining
Duplicate Cast
Heel Build Up (up to1") (1) L inch   R inch
Sole Flare (1) LR     Heel Flare (1) LR
Sole Wedge (1)            Heel Wedge (1)  L R
Metatarsal Bar (1)L R
Leather Toe Tips(2)
Reinforce for Brace (1)LR

SPECIAL INSTRUCTIONS
•  Please See "Casting Instructions"
•  Include A Weight-Bearing Tracing "Over"

*There is an additional charge for this modification unless chosen as a substitution under "Create a Package" see price list.
 


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