Consultation Form Orthotics Phone Last Name: First Name: Initials Date of Birth: Weight: Shoe Size: 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9 9.5 10 10.5 11 11.5 12 12.5 13 13.5 14 14.5 15 15.5 16 16.5 17 Mailing Address: Email Address: Postal Code: Home Phone: Cell: Marital Status: Married Single Divorced Widowed Gender: Male Female Is this a Workman's Compensation Case? Yes No Who referred you to our center? Your major complaint or symptoms are: ALL previous surgeries, illness and injuries: Have you worn orthotics before? Yes No Family Doctor's Name: Orthotics are custom made, prescription-based, foot corrections, as a result, they are non-refundable. In an effort to make you the most accurate orthotic we will modify your prescription once. Any further modifications will be charged to you, the patient. Date: Do you agree to the conditions? * YesNo