Diabetic Shoe Clinic- Certificate of Medical Necessity and Prescription

Name*

First NameLast Name

Date of Birth*

Date

I Certify that all the following statements are true

Type 1 DiabeticControlledType 2 DiabeticUncontrolled

History of partial or complete amputation of the footPeripheral neuropathy w/evidence of callus formationHistory of previous foot ulcerationFoot DeformityHistory of pre-ulcerative callusPoor circulation

3: Within the past 3 months an exam has been preformed andqualifying condition(s) have been documented

4: I am treating this patient under a comprehensive plan and care for his/her diabetes. DATE LAST SEEN*

Date

5: This patient needs special shoes (depth or custom-molded)and/or inserts because of their diabetic condition

(M.D. or D.O. ONLY)

Physician Name*

Phone*

Format: (000) 000-0000.

Fax*

NPI*

Todays Date*

Date

Address*

Physician Signature*

Upload Patient Notes here or Fax to (859)545-4989

Certificate of Medical Necessity

Prescription for Therapeutic Shoes & Inserts