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Compression Hosiery Appointment Request
Please take a moment to complete our client questionnaire, so we can learn more about your needs and preferences in preparation for your appointment
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1
Legal Name
*
This field is required.
First Name
Last Name
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2
Chosen Name (if different from legal name)
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3
Email
*
This field is required.
example@example.com
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4
Preferred Phone Number
*
This field is required.
Please enter a valid phone number.
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5
Phone Type
*
This field is required.
Mobile Phone
Landline
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6
Sex (assigned at birth)
*
This field is required.
female
male
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7
What is your shoe size?
*
This field is required.
indicate US Mens/Women's (e.g. W9.5) OR European (e.g. 40)
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8
Do you have a valid prescription for compression hosiery or will you get one BEFORE your appointment at Urban Soles?
*
This field is required.
Please note that medical compression hosiery (i.e. 20-30mmHg and higher) REQUIRES a prescription from a qualified physician
YES
NO
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9
Is your prescription NO older than 12 months?
*
This field is required.
Your prescription for compression hosiery must
not
be older than 12 months
YES
NO
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10
What compression grade have you been prescribed?
*
This field is required.
20-30mmHg
40-50mmHg
30-40mmHg
50-60mmHg
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11
Please submit a copy of your compression hosiery prescription and bring it to your appointment as well
(must be no older than 12 months)
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
By submitting a copy of your prescription, you consent to the collection and storage of your information on behalf of Urban Soles
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of
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12
What hosiery style do you require?
*
This field is required.
calf
thigh
pantyhose
wraps
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13
How many pairs of compression hosiery do you require?
*
This field is required.
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14
Have you worn medical compression hosiery before?
(i.e. compression of 20-30mmHg or higher)
YES
NO
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15
What fabric preferences do you have (if any)?
*
This field is required.
Select all that apply
Natural fibres (cotton, linen, merino wool)
Microfibre
moisture-wicking
breatheable
temperature-regulating
soft
cushioning
sheer
opaque
durable
no preferences
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16
What footwear do you wear most of the time?
*
This field is required.
choose the best option
Dress
Athletic
Casual
Work Boots
Sandals
Slippers
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17
What footwear do you wear the rest of the time?
choose the best option
Dress
Athletic
Casual
Work Boots
Sandals
Slippers
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18
Where do you spend most of your day?
*
This field is required.
Indoors
Outdoors
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19
What conditions are you exposed to for the most part of your day?
*
This field is required.
Select all that apply
Heat
Cold
Moisture
None of the above
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20
Do you have any contact allergies?
*
This field is required.
Select all that apply
Wool
Latex
Other
None
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21
Do you have sensitive skin?
*
This field is required.
YES
NO
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22
Do you have sweaty feet or issues with foot odour?
*
This field is required.
YES
NO
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23
Please indicate whether you have any of the following conditions
*
This field is required.
Select all that apply
Athlete's foot
Nail fungus
Other transmissible foot condition(s)
Leg ulcer(s)/open wound(s)
Diabetes
Peripheral neuropathy / Lack of protective sensation (lower extremities)
None of the above
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24
Your compression hosiery will be ordered for you from the manufacturer, and payment is due on the first visit (i.e. when we take measurements/place your order). Please refer to our website for pricing or inquire within (E.G. SIGVARIS 20-30mmHg in calf-length compression stockings start at $160). We provide our clients with a receipt they can submit to their extended health benefits provider (Note: We do NOT direct-bill insurances). Please confirm your insurance coverage (if applicable) before booking your appointment at Urban Soles!
Do you agree to our terms and conditions?
YES
NO
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25
How did you hear about us?
Healthcare provider
Rainbow Health
Lumino Health
CSI community
Google
Facebook
Co-worker
Friend/family
Other
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26
Consent To Data Collection And Storage
*
This field is required.
By submitting this form you consent to the collection and storage of your information at Urban Soles. If you have provided personal or other voluntarily provided information, you may access, review, and request changes to it by emailing us at drhess@urbansoles.ca. We will try to accommodate any requests related to the management of personal information. However, it is not always possible to completely remove or modify information in our databases (for example, if we have a legal obligation to keep it for certain periods of time).
YES
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Medical Compression Hosiery Questionnaire
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