Patient Name Age Weight Occupation/Activity Prescriber s Name Prescriber s Phone Date Casted Zip Bill Credit Card (complete reverse side) Lab Use Only RIGHT LEFT Sex Diagnosis Type of Shoe: (circle) Athletic Cleat C P S F Shoe Type of Orthotic o Red, White & Blue o Blue Rigid Neutral Shell o Polypropylene o Ultrathin o Shocker o Modified Shocker o Shocker Plus o Pro Shocker o Sport Flex o Performance Graphite o Fashion Fit o UCB o Lo Pro o Ortho Arch o Tenderfoot Soft.
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How to fill out the MD Foot Management Prescription Form online
Completing the MD Foot Management Prescription Form online is a straightforward process designed to help users submit their foot management needs efficiently. This guide will provide clear instructions to ensure that all required information is correctly entered to facilitate a smooth submission.
Follow the steps to complete your MD Foot Management Prescription Form online.
- Click the 'Get Form' button to obtain the MD Foot Management Prescription Form and open it in your preferred document editor.
- Begin by filling in the account information, including the account number, account name, and shipping address. Make sure the details are accurate and up-to-date.
- In the patient details section, enter the patient name, age, weight, and occupation/activity. This information is crucial for personalized treatment.
- Complete the prescriber’s information by inputting the prescriber’s name and phone number. Be sure to include the date the casting took place.
- Select the appropriate type of shoe by circling your choice: Athletic, Cleat, or Custom. This helps in determining the type of orthotic needed.
- Choose the type of orthotic required by marking the corresponding option. Note the options available, such as Red, White & Blue or UltraThin, among others.
- Indicate the cut and width of the orthotic by selecting from the available options. Specify your preference for length and any additional accommodations as necessary.
- Fill out the posting/measurements section, noting any specific adjustments needed for the right and left orthotics.
- If you have any rush options or additional requests, be sure to indicate these in the relevant sections, as there may be additional charges.
- Once all sections are completed, you can save your changes, download the form for your records, print it, or share it as needed.
Complete and submit your MD Foot Management Prescription Form online today for efficient foot care management.
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