PATIENT FORM

PRIMARY INSURANCE MUST BE MEDICARE!

Payment for shoes, insoles and/or other devices is due at time of service.

PLEASE COMPLETE INFORMATION:

MEDICARE NUMBER_______________________________________________________________

NAME____________________________________________________________________________

ADDRESS_________________________________________________________________________

CITY_____________________________________________________________________________

STATE____________________________________________________________________________

ZIP CODE_________________________________________________________________________

PHONE#__________________________________________________________________________

DATE OF BIRTH__________________________________________________________________

Please bring your Medicare Card with you, we need a copy for our records!!

I authorize Terry Thompson, C-Ped. O. T. to submit a claim to Medicare in my
behalf for reimbursement of shoes, insoles and/or other devices and/or services.

Cobbler's Corner does not bill private insurance companies or secondary insurance
companies (Medicare does this). If you have any questions, please ask.

Signature._________________________________________________________________________

Date.__________________________________                                            
11/07

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PLEASE READ THE FOLLOWING:

As professionals we want you to have the best care!

Suggested guidelines for wearing pedorthic devices (which include Therapeutic shoes, shoe modifications
and foot orthoses):

1. Wear the shoes for 2 hours, take off and physically examine the foot
    (if you cannot see the bottom of your feet use a mirror or have someone else examine your foot).
    Look for anything out of the ordinary (like red spots, blisters or scrapes).
2. If everything looks all right put your shoes back on and wear for 3-4 more hours and repeat step # 1.
3. If everything looks good put your shoes back on and wear the rest of the day.
    At bedtime take off shoes and repeat step # l.

If any problems arise PLEASE discontinue use of shoes and call for an appointment.
When you call, please inform us you are a Diabetic so we can get you in as soon as possible.

A follow up visit is a very important part of your Health Care. Your first visit should be after you wear the shoes
for 2 weeks. Then you should have follow up visits every 4 months, for us to help monitor how the shoes are
functioning with your feet. This helps us to ensure that your shoes, insoles and feet are all functioning well together,
and to do any necessary adjustments.
All check ups and visits with Terry Thompson, C-Ped,
Kimberly Binegar, C-Ped, and Patricia Wilkins, C- Ped, require an appointment.

Patient compliance is the key to successfully implementing a Diabetic footwear program in the
Pedorthic practice.

FOOTWEAR WARRANTY INFORMATION: Every product sold by our company carries a manufacturer's
warranty against defects in the manufacturing or materials. Cobbler's Corner will notify all Medicare beneficiaries
of the Warranty coverage, and we will honor all warranties under applicable law. Cobbler's Corner will repair
or replace free of charge, Medicare-covered footwear that is under warranty.

I have read and understand the above information:

Signature_________________________________________________________________________

Date______________________________________