Patient Intake Form
Personal
Date of Birth
Medical
Medical Contitions
Arthritis
Diabetes
Fibromyalgia
Heart
Stroke
Venous Isufficiency
Reason for Visit
Custom Made Orthotics
Custom Sport Orthotics
Compressions
Custom Made Compressions
Off-the-Shelf Shoes
Custom Made Shoes
Employment / Insurance
Do you have a Prescription?
Yes, I have a Prescription
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