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Thank You For Inquiring About Our Services
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1
Full Name
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First Name
Last Name
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2
Email
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example@example.com
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3
Preferred Phone Number
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Please enter a valid phone number.
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Type Of Phone
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Mobile Phone
Landline
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Best Time(s) To Reach You
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Please indicate when you can be reached by phone
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6
Preferred Appointment Day
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We accept new patients Tue - Thu
Tuesday
Wednesday
Thursday
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7
Preferred Appointment Time
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10AM - 7PM
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Minutes
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8
What Can We Help You With?
Select all that apply
Foot & Ankle Pain
Shin Splints (Shin Pain)
Custom Orthotics
Orthopaedic Footwear
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9
Do You Have Extended Health Benefits That Cover Custom Orthotics?
YES
NO
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10
Did You Obtain A Prescription For Custom Orthotics From A Qualified Healthcare Professional (e.g. Physician) Within The Past 12 Months?
Please note, you do NOT need a prescription or referral for custom orthotics! We ask this for logistical purposes.
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NO
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11
Consent to Data Collection And Storage
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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).
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