Vivally Intake Form

REQUIRED FIELDS
NAME -FIRST LAST*
GENDER*
DOB (MM/DD/YYYY)*
Address*

ADDRESS

Street Address Line 2

CITYSTATE

ZIP
MOBILE PHONE *
Format: (000) 000-0000.
EMAIL*
example@example.com
PREFERRED WRITTEN LANGUAGE*
PREFERRED SPOKEN LANGUAGE*
EMERGENCY CONTACT*
EMERGENCY PHONE*
Format: (000) 000-0000.
INSURANCE
PRIMARY PAYER NAME*
ID #*
GROUP #*
PHONE*
Format: (000) 000-0000.
POLICY HOLDER DOB (MM/DD/YYYY)*
PRIMARY POLICY HOLDER NAME*

First NameLast Name
RELATIONSHIP TO PATIENT*
SECONDARY PAYER
ID #
GROUP #
RELATIONSHIP TO PATIENT
Format: (000) 000-0000.
SECONDARY POLICY HOLDER NAME
POLICY HOLDER DOB
RELATIONSHIP TO PATIENT
PATIENT SIGNATURE*

Clear
Date*
PERSONAL REPRESENTATIVE
Personal representative: If the individual signing this form is not the patient, please print name and specify relationship to the patient; if Power of Attorney, please provide documentation.
PERSONAL REPRESENTATIVE,
Date
PDF
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COPYRIGHT © 2023 2025, AVATION MEDICAL, INC. ALL RIGHTS RESERVED. AVATION MEDICAL AND VIVALLY ARE TRADEMARKS OF AVATION MEDICAL. MKT 002-00143

FULL NAME *
Medical Practice Name*
Patient or Legal Representative Signature Authorizing Release*

Clear
Printed Name*
Date*

MonthDayYear
Date
Patient or Legal Representative Signature for Appointment of Representative*

Clear
Legal Representatives Relationship to Patient
Printed Name
Date

MonthDayYear
Date

NAME - FIRST & LAST*
DOB (MM/DD/YYYY)*
Address*

SHIPPING ADDRESS

Street Address Line 2

CITYSTATE

ZIP
MOBILE PHONE*
Format: (000) 000-0000.
EMAIL*
example@example.com
ii. Measure:Measurement 1: Ankle Circumference just above ankle bone on bare ankle. Record Measurement 1 in centimeters.*
Measurement 2: Middle of Foot Circumference at the arch on bare foot. Record Measurement 2 in centimeters.*
Vivally Small. Ankle AND Foot measure between 19.0 cm - 23.9 cmVivally Medium. Ankle OR Foot measure between 24.0 cm - 28.5 cmVivally Extender. Ankle OR Foot measure greater than 28.5 cm