1 Umfang der erforderlichen Schuhausstattung
2 Erforderliche Leistungen
Foot orthotics
boolean
Orthopedic adjustment of ready-made shoes
boolean
Orthopedical ready-made shoes
boolean
Semi orthopedic shoes
boolean
Custom made orthopedic footwear
boolean
3 Orthopädische Schuhausstattung: Schuhform/Schuhhöhe
3 Orthopädische Schuhausstattung: Schuharten orthopädische Schuhe
Outdoor shoe
boolean
Slipper
boolean
Sports shoe
boolean
Bathing shoe
boolean
Therapeutic shoe
boolean
Winter boot
boolean
Work shoe, if known
boolean
Work shoe: Safety shoe S 1
boolean
Work shoe: Safety shoe S 2
boolean
Work shoe: Safety shoe S 3
boolean
Sonstiges
Order required by service provider
boolean
Medical acceptance required
boolean
Rationale and goal of therapy of orthopedic shoes
text
Further comments
text
Date
date
Signature/stamp
text