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Customer Information:
Company:
Name:
Address:
City, State & Zip
Phone #:
Email Address:
Insurance Information:
Member ID #:
Insured's Name:
Physician Information - Must have approval from your physician
Physician Name:
Address:
Phone Number:
Please check all that applies below:
____ Edema or Swelling ____ Heel Pain Other Pain:
____ Foot Tenderness or Discomfort ____ Plantar Pain
____ History of DVT ____ Ankle Pain
____ Varicose Veins ____ Knee Pain
____ Tarsal Pain - Toes ____ Lower Back Pain
____ Neuropathy ____ Diabetes
____ Shin Splints ____ Wrist/Hand or Elbow Pain
Please check all that applies below: Measurements:
____ Stand for prolonged periods of time while working Height: ______
____ Sits for prolonged periods of time while working Weight: ______
____ Wears steel-toed or composite toed boots Shoe Size: _____
____ Walks on uneven surfaces
____ Constantly lifting items over 50lbs.
____ Performs same motion for extended periods of time
____ Frequent airplane travel
*** Shoe orders will ship out seperately from compression orders. Please allow 5-6 weeks for processing.
Signature: ________________________________________________________ Date:Date: _________________
Group #:
Date of Birth:
Primary Insurance Company Name:
PO Box 4837, Mooresville, NC 28117Telephone: 704-799-2873 Fax: 704-663-4369 Alternate Fax: 704-664-0226
Date of Birth:
Patient Registration Form - Orthopedic Footwear & Bracingwww.occfitsolutions.com
Fax Number:
Size-Range Conversion Chart - Circle Size Name:Women's US 4.5 -5 5.5 - 6 6.5-7 7.5 - 8 8.5 - 9 9.5 - 10 10.5 - 11 11.5 - 12 12.5 - 13
Women's EU 35 36 37 38 39 40 41 42 43
Men's US 7.5 - 8 8.5 - 9 9.5 - 10 10.5 - 11 11.5 - 12 12.5 - 13 13.5 - 14 14.5 - 15
Men's EU 41 42 43 44 45 46 47 48
Women's Collections - Circle Style and Color Below
FAWNA (35-43)
Black Milled Nappa
FRANNY (36-42)
Milled Black Nappa
ALISSA (36-42)
SAM (36-43)
Black Leather
JANE (36-42)
Black Burnished Full Grain
PEPPER (36-42)
Black Nappa Leather
CAMELLIA (35-43)
Black Leather
CORAL (35-43)
MARCELLE (35-43)
Black Nappa Leather
Black Patent Leather
STEFFI (36-42)
Black Leather
Black Milled Nubuck
Smooth Black Leather Black Suede (36-42)
SHAINA (36-42)
Black Tumbled Leather
JULIA (36-42)
Milled Nappa Leather Black
LILIANA (36-42)
Black Burnished Nubuck
WINONA (35-43)
Milled Nappa Leather Black
PROFESSIONAL (35-43)
Black Patent (Medium/Wide)
Black Cabrio (Narrow/Med/Wide)
EMMA (36-42)
Black Oiled(Medium/Narrow
LORALIE (36-42)
Red Burnished Nubuck
JOSIE (36-42)
Black Nappa Leather
LISANNE (36-42)
Black Milled/Patent
Black Burnished Nubuck
PAISLEY (Slip & Waterproof)
Black Leather
Black Nylon/Leather Black Patent
Black Leather w/ Lycra
Black LeatherDark Brown (5 - 11M/W)
Black Nubuck Leather
LINETTE (36-42)Black Milled Nappa
WILLA (35-43)Black Leather Black Leather
CLARISSA - (4M/N/W-12M)
VOYAGE (6M-11M)Black Leather
VENECIA (4M-12M)Black Leather
MICHELLE (5M/N-12M)Black Leather Black Leather - 2" Heel
FLUTE (4-12N/M/W/EE)Black Patent
Black Shiny
COCO (5.5 - 12M/W/EE)
Black Tumble Leather
Black LeatherCHANNING (5.0M-10M)
Black Leather
Black Leather
DEV (4M-12M)
CINDEE (5.5 - 12M/W/EE)Black Leather
VIGOR (4-12N/M/W/EE)DAPHNE (35-42)Brown (5 - 11M/W)
HARRISON 6" - STEEL/SOFT TOEPIPER - COMPOSITE TOE
ELLIE (36-42)
EMILY (4.5M/W-12M)Black Leather
EMILINE (4M/N/W - 12M)
JOY (36-42)
Red Nubuck Leather
MERRY JANE (5.5-11M/W/EE)Black Tumbled Leather
ChestnutBlack (5 -10M/W)
Black Leather
KELI (35-44) ESSENCE (35-42)
CLEMENTSBlack Leather
FREEDA (2 1/4") Black Leather
AVALA (2" Heel) Black Leather
Black Leather
(5 - 13N/M/W/EW) White Leather
Black Leather - M/WJet Luster - M/W
ELLA (35-42)Black Leather - M/W
SAN MARINO
Black Leather w/ Stretch
TOBY IIMOCHOBlack Leather
DAYNA (35-41)Black Leather - M/W
MAYA DREAM FIT (36-42)Black Stretch - M/W Black Dusty Leather
MONACO SUMMER Black Leather
HAVANA (4 - 13N/M/W)
Black Leather
LONDON II (5-13N/M/W/EW)
BLACK STRETCH
AMERY
Black Leather
BURR Black Leather
DREW FUSION (5-13N/M/W/EW)
Black Leather
ALGRIA ERYN Jet Luster
ANETO Black Leather
BRANNING CAP TOEXC4 - BRANNING WINGTIP
Black Oiled Nubuck
Brown Oiled Nubuck
Black Leather
7 - 16 (N/M/W/4W)
Black (7 - 14) Black (8 - 13) Black (7 -12M/XW) Black (8 - 13)
XC4 - HOLLIS PLAIN TOE
Tan (7 - 14) MAHOGANY (8-13) Mahogany (8 - 13)
8 - 16 (M/W/4W) 8 - 16 (M/W/4W) 7 16 (N,M,W 4W)
XC4 - STANTON MOC VEN
JOSH (41-47)
Black Leather
Taupe Milled Nubuck
Mahogany Antiqued Calf
JUSTIN (41-48)
FULTON
Black Tumbled Leather
Dark Brown
Black Tumbled
Brown Tumbled
TREK
Black Nubuck
Dark Brown
BOULDER - COMPOSITE TOE
OZ - ALLEGRIA (41 - 48)
Black Leather
White Leather
VOYAGER ROCKFORD - COMPOSITE TOE
JACKSON (41-47)
Black Leather
Mahogany Antiqued Calf
Black Tumble
OMAHA
Black Leather
DECKER
Black Leather
BAINBRIDGE
Black Leather
ANTHEM - Steel/Soft Toe DURBIN - Steel/Soft
(7 - 14 M/EW) (6 - 15 M/EW)
(7 - 14 M/EW) (7 - 14 M/EW)
(7 - 15 M/EW) ( 7 - 14 M/EW)
( 3 - 14 M/W)
( 7 -14 M/EW) (6 - 14 M/EW)
( 6 -15 M/W)
Brown
CHROME - 6" or 8"KHYBER - 6" or 8"
Black Waterproof
Brown
I-90 EPX CARBONMAX BOOT
Black
KHYBER HOT WEATHER
Black Leather
Brown
Black
Red
Black/Grey
Metallic Blue/Grey
Metallic Red/Grey
LEGEND - Composite/Soft Toe
Black
Grey/Black
(6 - 15 M/W/EW)
DURASHOCKS SR - Composite/Soft
Brown
Black/Grey
JASON (7.5 - 14 M/W/EW)
Blue
ENDURANCE PLUS
Black
CHRIS (7.5 - 14 M/W/EW)
Brown
White
Black
(6 - 15 M/W/EW)
Black Leather
JETSTREAM 2 CARBONMAX
Black - Safety Toe
RUSH ESD
Black - Safety Toe
Black - Composite Toe
** PLEASE INDICATE TOE PREFERENCE - SOFT, STEEL OR COMPOSITE
RAIDER - Steel/Soft Toe
Black - 6" only
PERFORMANCE
Brown
DELTA 6"
Black
Circle area of that experiences pain/discomfort and explain below:
SPECIFTY RIGHT OR LEFT
Back Support Products:
Ankle & Foot Supports:
Knee Supports: Wrist Supports:
Elbow Support:
Plantar Fasciitis Night Boot
Orthopedic Wrist Brace
Maternity Support
Epicomed Elbow
Genumedi Knee Genumedi Pro Knee Manumed Active
Ankle SupportAchilles Tendon Support Ankle Brace
Lumbamed Plus Postural Control Brace Cincher Back Support
