URBAN SOLES Contact Request Form

1

Full Name* This field is required.

First Name

Last Name

2

Chosen Name(if different from full name)

First Name

Last Name

3

Preferred Email Address* This field is required.

example@example.com

4

Preferred Phone Number* This field is required.

Please enter a valid phone number.

5

Type Of Phone* This field is required.

Mobile Phone

Landline

6

Best Time(s) To Reach YouPlease indicate when you can be reached by phone

7

What Can We Help You With?* This field is required.Select ALL that apply

Chronic Foot & Ankle Pain

Shin Splints (Shin Pain)

Custom Orthotics

Orthopaedic/Diabetic Footwear

Medical Compression Hosiery

Other

8

How Urgent Do You Require To Be Seen?Please note that we do NOT treat acute injuries (e.g. fractures, ankle sprains, tears) and that there may be times when we cannot accept new patients

Within a week

Within two weeks

No preference

Other

9

Preferred Appointment Time (Office Appointment)?Select ALL that apply!

Morning (10-11am)

Afternoon (12-4pm)

Evening (5-7pm)

10

When Are You NOT Available (Office Appointment)?Please indicate when you are NOT available for an office appointment (days + times )

11

Do You Have Extended Health Benefits That Cover Custom Orthotics?

YESNO

12

Did You Obtain A Prescription From A Qualified Healthcare Professional (e.g. Physician) Within The Past 12 Months For The Service You Require (e.g. Custom Orthotics, Compression Hosiery, Orthopaedic/Diabetic Shoes)?Please note, you do NOT need a prescription or referral for custom orthotics if you are not seeking reimbursement from your extended health benefits provider.

YESNO

13

Consent to Data Collection And Storage* This field is required.By submitting this form you consent to the collection and storage of your information on behalf of 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).

YESNO