Therapeutic Footwear Prescription
Use this form to request therapeutic footwear prescription details, patient information, and clinician instructions.
Patient Information
Patient Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Therapeutic Footwear Prescription Details
Diagnosis or medical reason for therapeutic footwear
*
Required footwear type
*
Extra-depth shoes
Custom shoes
Orthotic-compatible shoes
Post-op footwear
Other
Feet affected
*
Left
Right
Both
Size or fitting notes
Special instructions or modifications needed
Prescriber Details
Prescribing Clinician Name
*
First Name
Middle Name
Last Name
Prescriber License / Reference Number
Submit
Should be Empty: