Patient Registration Form - Orthopedic Footwear and Bracing 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Customer Information section. Enter your company name, full name, address, city, state, zip code, phone number, and email address.
3. Next, provide your Date of Birth in the designated field.
4. In the Insurance Information section, input your primary insurance company name, member ID number, insured's name, group number, and date of birth.
5. Complete the Physician Information section by entering your physician's name, address, phone number, and fax number. Ensure you have their approval for this form.
6. Check all applicable boxes regarding your medical history and current conditions related to foot health.
7. Fill in your measurements: height, weight, and shoe size in the Measurements section.
8. If applicable, specify any special orders including manufacturer details and color preferences.
9. Finally, sign and date the form to confirm that all information is accurate before submitting it through our platform.

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