Form-Orthotics Consultation | Chiropractic Wellness Centre

Last Name:

First Name:

Initials

Date of Birth:

Weight:

Shoe Size:

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?

Yes No

Consultation Form

Orthotics