Client File

Today's Date

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Postal Code

Work Phone

Home Phone

Cell

Are you ok with a reminder text/phone call 24 hours in advance of your appointment?

Yes

Height

Weight

Shoe Size

Date of Birth

Occupation

Family Doctor

Referring Professional

If you have a referral please upload it here (pdf, jpg, jpeg, png, doc, docx supported)

Choose File

Parent/Guardian Information

If you are under 19 please input your Parent/Guardian Information.

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Phone/Cell

In order for us to give you the appropriate documentation, please Click Yes or No if you have an extended health plan:

Yes

Please Note

If you have clicked YES and decide to go ahead with orthotics, please don’t send anything to your extended healthcare providers until your final appointment, as we will be giving you an entire package with all the information that they require, as it pertains to your visit with us.

If extended health package is lost or misplaced, we will replace it for a $20.00 charge.

Important Information

Orthotic prices vary to match the individual personal needs. Typically, orthotic fees range from $485.00-$550.00. This price includes fabrication of the orthotics, fitting of the orthotics and any adjustments, if required. There is a one-time $75.00 fee for the biomechanical evaluation and assessment.

We are committed to providing the best support for every patient. If proceeding with orthotics, due to the custom nature of the work, a non-refundable deposit of 50% is required. Please appreciate the human body is very dynamic and it is difficult to guarantee outcomes; as such there are no refunds, exchanges or credits for custom products/services. If you have any questions please discuss them with your Pedorthist. *Orthotics will NOT be dispensed without a referral from a physician. **Orthotics not picked up after 90 days will no longer be held.

We cannot share your information. Your file is private and confidential and only with your consent can we share your information regarding your file with your Doctor.

I authorize Progressive Step Orthotics and Bracing to collect my personal and medical information as documented above. In addition I authorize Progressive Step Orthotics and Bracing to communicate with my family doctor or referring professionals as deemed necessary for comprehensive treatment.

Parent/Guardian Information

Please Note

Important Information

about

resources

contact