ORTHOTIC INFORMATION FOR PATIENTS
Orthotic alone With “basic” footwear
For Orthotics Fitting: New Patient Assessment and orthotics fitting
Ordering the orthotics
One month later an appointment to insure proper fit
Follow up one year after receiving orthotics
Total cost of custom orthotics is
$ 80.00
$ 420.00
$
0.00
$
0.00
$ 500.00
$ 80.00
$ 500.00
$
0.00
$
0.00
$ 580.00
When the orthotics are ordered, usually on your first visit; you must pay for the orthotics in full as a deposit. The
receipt for your insurance company will be issued when you pick up the orthotics, on dispensing.
Do You Need Orthotics? How do I know if I have a problem?
The symptoms of poor foot mechanics can include any one of the following:
 Localized foot pain
 Leg or knee pain
 Bunions, hammer toes
 Hip or back pain
 Arch or heel pain
 Plantar fasciitis
How can orthotics help? Properly made orthotics are custom moulded, to the support requirements of your
feet. They help restore the normal balance and alignment of your body by gently correcting foot
abnormalities.
Who will fit me for orthotics? We will be doing orthotics assessments for custom orthotics. Orthotics will be
ordered and made at The Orthotic Group laboratory. We have training from the continuing education
program at The Orthotic Group.
Orthotics billing includes getting a detailed history, gait observation (pattern of walking), orthopaedic testing,
and gait analysis by using a gaitscan which scans the foot, maps foot pressure and produces a 3D image to
make your custom orthotics. Also included is your fitting appointment when the orthotics come in and you
come back in to pick them up, after one month we will contact you to ensure proper fit and that you are
adjusting to using your new orthotic. We will also contact you one year after you receive your new orthotic to
ensure you are still happy. We would encourage you to contact us at anytime if you have questions or
concerns, especially if your new orthotic is not comfortable to wear.
We select an orthotic that fits you best and they can be specifically made for:
 Dress Shoes  Soccer Cleats  Ski boots and skates  Casual Shoes  Golf Cleats
 Court Shoes  Extra Cushion  Running Shoes  Diabetic Feet  Specific for safety shoes /boots
If you have insurance coverage, call your provider today and see what requirements are needed:
Decide what shoes you plan on wearing your orthotics in and tell the chiropractor on your first visit. Dress shoes,
running shoes, work boots etc. all have a different thickness of orthotics required to fit perfectly into different
shoes.
Can a
Chiropractor
dispense?
If not who?
Who can
prescribe?
Chiropractor
Podiatrist
Chiropodist
Med. Doctor
Casting method:
3D Volumetric (Foam
cast) and or accepted?
Or 2D Pressure cast
from digital imaging
(gaitscan) accepted?
Percentage
of cover
Annual
limit or
maximum
Are they
eligible to
claim?
When was
the last
claim?
Renewal:
1 year
2 year
Rolling
Custom Orthotic
Orthopedic Shoes
Compression Socks
How long until I will have my orthotics? Orthotics usually takes 2 – 3 weeks to be delivered to us. When the
orthotics come in we will call you to make a follow up appointment for you to pick up your orthotics and make
sure they fit you and your shoes perfectly. You will be provided with a report for your insurance company on
how the orthotics were made and the reason you required orthotics.
t: 7055266900
357 King Street, Midland, ON L4R 3M7
www.healthworkscentre.com
f: 7055266460
healthworks
ORTHOTIC ASSESSMENT
chiropractic & wellness centre
357 King Street, Midland, Ontario L4R 3M7 Tel: 526-6900 Fax: 526-6460
www.healthworkscentre.com
Personal History
Date: ____________________
Name: ___________________________________________ Address: ________________________________________
City: ____________________________________________
Province: ___________ Postal Code: _______________
Email Address: ____________________________________________________________________________________
Home Phone Number: _____________________________
Birth Date: ___ __/______/
Age: _________
Cell Phone Number: ______________________ Provider: ___________
DD / MM / YYYY
Business/Employer: ________________________________ Occupation: ____________ Business Phone:_____________
Gender:  Male  Female
Circle One: Married Single Widowed Divorced Separated
Spouses Name: ___________________ Number of Children:________ Ages: _____________
Do you have insurance?  Yes  No Insurance Provider:______________________
Who may we thank for referring you to this office? _________  Yellow Pages  Ads  Other____________
A 100% deposit on ordering Orthotics, a receipt for the purchase provided on the dispensing date. _______ (initial)
Current Health Conditions
Current Complaints: ________________________________________________________________________________
Family Doctor ____________________________________ Does your MD know about this condition?  Yes  No
If yes, type of treatment: ___________________________
Results: ______________________________________
When did this condition begin? ______________________
Has this condition occurred before? _______________
Is this condition: Job-Related (WSIB)  Auto-Related
 Home Injury  Fall  Other _______________________
Date of Accident: __________________________________
Time of Accident: ______________________________
Chief Complaint (Please check off all that applies)









 Relief with Walking
 Increase pain with standing
 Shin Splints
 Uneven Shoe Wear
 Callus or Corns
 Bunions
 Hallux Valgus
 Leg Length Difference
 Peroneus Tendonitis (outside leg
muscle strain)
 Abnormal Gait
Family History of Foot Problems
Pain on Walking
Morning Pain
Sore Feet
Heel Pain
Knee Pain
Hip Pain
Ankle Pain
Lower back Pain
 SI Joint Irritation
Activity:









Planter Fasciitis
Collapsed Arch
Achilles Tendinitis
Heel Spurs
Patella Tendinitis
Patella Femoral
Morton’s Neuroma
Metatarsalgia (numb foot arch)
Chondromalacia
 Do you spend a good portion of the day walking or standing?
 Do you play sports regularly? (Hockey, Golf, Running, ect,..)
 Does walking or running result in joint pain (ankle, knee, hip, or back)?
 Do you consider yourself over weight?
 Do your feet “toe-out” or “toe-in” when you walk?
t: 7055266900
357 King Street, Midland, ON L4R 3M7
www.healthworkscentre.com
f: 7055266460
INFORMED CONSENT FOR CHIROPRACITC EXAMINATION AND FOOT ORTHOTIC THERAPY
Your chiropractor has prescribed medical devices for you called custom foot orthotics.
Orthotics can be an integral part of patient care by health care providers for the management of
pedal pathologies and musculoskeletal symptomatology, and to alleviate pain and discomfort from
abnormal foot function. Abnormal foot function may affect a patient’s kinetic chain, including legs,
knees, hips and spine. Orthotics are designed based upon the degree of patient abnormal foot
function, patient activity level, patient physical stature and the type of footwear in which the
orthotics are worn. Custom orthotics are foot inserts placed inside footwear.
What is the Process?
Your chiropractor will assess your foot function in order to determine if you require foot
orthotics and if you do, what type of orthotics will benefit you most. The next step is capturing your
foot image and sending that image to a custom foot orthotics laboratory that will make a device
specific to your foot. This process usually takes about 2-3 weeks. When the orthotics arrive back at
this location, your chiropractor will ensure the devices fit and function properly and your
chiropractor will explain the “break in” instructions.
What should I expect when wearing the orthotics?
Many patients experience pain reduction and increased comfort when wearing custom foot
orthotics. A small percentage of patients experience discomfort and/or pain when breaking in their
orthotics and an even smaller percentage of patients experience significant enough pain that they
cannot wear their orthotics at all.
Consent
I have read the information above and hereby request and consent to the performance of
the assessment of my foot function and the prescription of custom foot orthotics.
I have had an opportunity to discuss with the chiropractor the nature, purpose, benefits and
risks of custom foot orthotics. I understand and am informed that, as in the practice of medicine, in
the practice of chiropractic there are some risks to treatment with custom orthotics, including, but
not limited to, foot pain, leg pain, back or neck pain. I do not expect the chiropractor to be able to
anticipate and explain all risks and complications, and wish to rely on the chiropractor to exercise
judgment during the course of the procedures which the chiropractor feels at the time, based on
the facts then known, are in my best interests.
I have read or have had read to me the above consent. I have had the opportunity to ask
questions about its content and by signing below I agree to the above named procedures. I intend
this consent form to cover the entire course of treatment for my present and for future condition(s)
for which I seek foot orthotics treatment.
TO BE COMPLETED BY THE PATIENT OR BY THE PATIENT’S REPRESENTATIVE IF THE PATIENT IS A MINOR OR
PHYSICALLY OR LEGALLY INCAPACITATED. Date Signed: (
)
____________________________________
Patient Signature
t: 7055266900
______________________________________
Witness Signature
357 King Street, Midland, ON L4R 3M7
www.healthworkscentre.com
f: 7055266460