Orthotic Device Consent Form
Please read and provide your consent for the orthotic device treatment.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Description of Orthotic Device
*
Purpose and Benefits of the Orthotic Device
*
Potential Risks and Complications
*
Patient Consent Statement
*
Patient Signature
*
Date of Consent
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: