New Patient Intake Form

First Name

Last Name

DATE OF BIRTH

HEIGHT:

WEIGHT

SEX:

Male Female

ADDRESS:

CITY:

POST CODE:

TELEPHONE: CELL

TELEPHONE: HOME

TELEPHONE: WORK

OCCUPATION:

EMPLOYER:

FAMILY DOCTOR:

FAMILY DOCTOR: CITY:

FAMILY DOCTOR: PHONE

REFERRING DOCTOR:

REFERRING DOCTOR: CITY:

REFERRING DOCTOR: PHONE

RECREATIONAL ACTIVITIES:

SHOE SIZE:

WHAT TYPE OF FOOTWEAR DO YOU WEAR AT HOME

AT WORK:

PARENT/GUARDIAN (patient under the age of 18)

Parent Name

RELATIONSHIP:

INSURANCE

Do you have Extended Health Benefits?

YES NO

If eligible, please provide:

CONTACT PERSON

MEDICAL RELEASE

I hereby consent to the release of my personal medical records between Walking Mobility Clinics and my referring physician, family physician or other medical or insurance personnel if requested.

FEES
Assessment = $80.00
Orthotics = $549.00
Deposit for Orthotics at time of ordering = $250.00
NO FEES ARE COVERED BY OHIP

RETURN POLICY
Please be advised that custom made products are NOT eligible for refund, exchange or credit. Footwear and off-the-shelf bracing returned within 30 days of pick-up are eligible for refund/exchange. These products must be in new condition and in the original undamaged packaging. Items NOT eligible for return include: sale items, socks / compression stockings, foot / nail care products, shoe care products, toe straighteners, spacers, separators, crests, arch supports or heel cushion.

I acknowledge that I have read and understand the above MEDICAL RELEASE, FEES and RETURN POLICY. By signing, I agree to the terms and conditions set out above.