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Orthopaedic Footwear Consultation Request & Inquiry
Please take a moment to complete this short questionnaire, so we can learn more about your requirements 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
*
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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
Type Of Phone
*
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Mobile Phone
Landline
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6
Best Time(s) To Reach You
*
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Please indicate when you can be reached by phone
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7
Preferred Appointment Day
*
This field is required.
We accept new patients Tue - Thu
Tuesday
Wednesday
Thursday
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8
Preferred Appointment Time
*
This field is required.
10AM - 7PM
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Minutes
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PM
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9
Have You Had Stock (Non-Custom) Orthopaedic Footwear Before?
*
This field is required.
YES
NO
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10
Which Brand(s)?
Please list the brands/models of stock orthopaedic shoes you have worn previously (if applicable)
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11
What Is Your Main Reason For Choosing Stock Orthopaedic Footwear Today?
*
This field is required.
Comfort
Medical Reason(s)
Performance
Insurance Benefits
Customization Options (different widths etc.)
Other
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12
Do You Have Any Of The Following?
*
This field is required.
Select all that apply!
Bunions, Hammertoes
High Arches
Flat Feet
Swelling (Foot/Ankle)
Diabetes
Ulcers (Foot)
Foot/Ankle Pain
NONE of the above
Other
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13
Are You Wearing Custom Orthotics?
*
This field is required.
YES
NO
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14
Are You Experiencing Any Pain Or Discomfort In Any Of The Following?
*
This field is required.
Select All That Apply!
Foot & Ankle
Shin(s)
Knee(s)
Hip(s)
Low Back
Other
Not Applicable
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15
Will You Be Seeking Reimbursement From Your Extended Health Benefits Provider For Stock Orthopaedic Shoes?
*
This field is required.
If you do NOT have EHB, select NO
YES
NO
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16
Do You Have A Prescription For Stock Orthopaedic Shoes That Was Issued Within The Last 12 Months
*
This field is required.
Note: You do NOT need a prescription to purchase stock orthopaedic shoes
YES
NO
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17
How Did You Hear About Us?
Healthcare Provider
Rainbow Health
Lumino Health/Sunlife
CSI Community
Google
Facebook
Co-Worker
Friend/Family
Other
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18
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).
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Orthopaedic Footwear Consultation Request Form & Inquiry
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