CHIROPODY & ORTHOTICS CONSENT FORM

Chiropody assessments & Orthotics are NOT covered by the OHIP provincial insurance plan. These medical services & products(s) are covered by most extended health care plans (e.g. Blue Cross, Sun Life, ManuLife, Great West Life, Green Shield, Dejardins, etc). Please ensure you know what your coverage as you consent to your medical service & product. Payment is due in full before you may be fitted or pick up your medical product(s). Orthotics cannot be claimed or reimbursed from your insurance company until FULL PAYMENT IS MADE AND YOU HAVE A DETAILED RECEIPT OR YOU HAVE PREVIOUSLY ARRANGED FOR US TO DIRECT BILL YOUR INSURANCE PROVIDER WITH YOUR CONSENT & AUTHORIZED SIGNATURE . The clinic will issue receipts (if necessary). Since all medical product(s), especially Foot Orthotics, are “Custom made” for only your individual foot shape & size, and a detailed 3D scan and/or cast was made of your feet, they are both extremely accurate to you & “Non-Refundable”. A credit card such as a Visa, MasterCard, or Amex must be recorded in your file prior to processing the foot orthotics or you have signed your direct billing forms in full. I am aware & understand that there are other Chiropody & Orthotic suppliers in the area; yet, I would like to proceed on with the Chiropody assessment & Orthotics should they be deemed a medical necessity for my condition(s) and foot type I do CONSENT to the Chiropody & Foot Orthotics and I do understand and abide by the above medical product(s) clinic policy and wish to proceed with the order process. Once I sign this consent form, all medical products are custom measured; thus, “non-refundable” & cannot be cancelled or amended. This consent form, as per College regulations, must be signed prior to commencement of assessment or measuring/casting or laser scan for orthotic product(s) thank you.

** Orthotics may take up to 3-4 weeks or longer to complete in the Lab. **