< BACK TO FORMS PAGE

Patient Phone: _________________________ DOB:______________________________

Patient Name: ________________________________ Medicare #__________________

Address:_________________________________________________________________
                                                                        City            State                Zip

Statement of Certifying Physician & Prescription for:

Therapeutic Shoes and Inserts

1) This patient has diabetes mellitus: (please check one)

250.00 Type II controlled       250.01 Type I controlled

250.02 Type II uncontrolled    250.03 Type I uncontrolled

2) This patient has one or more of the following conditions: (please check all that apply)

 History of partial or complete amputation of the foot

 History of previous ulceraction         Poor circulation

 Peripheral neuropathy with evidence of callus formation

 History of pre-ulcerative callus          Foot Deformity

3) I am treating this patient under a comphrehensive plan of care for his/her diabetes, Arthritis or Raynaud's disease

4) This patient needs special shoes (extra-depth shoes) and/or inserts because of their diabetes

DX: Diabetes Mellitus (ICD-9 code 250.00 - 250.91)
RX: Extra-Depth Diabetic shoes and 3 pairs of heat molded multi-density inserts

Statement of Certifying Physician & Prescription for:

Ankle/Foot Gauntlet

1) This patient has Arthritis or Raynaud's Disease (please check one)

Arthritis      Raynaud's Disease     Diabetes

2) This patient has one or more of the following conditions: (please check all that apply)

 PVD     Poor Circulation        Rheumatoid Arthritis      Disuse Atrophy

 Peripheral neuropathy         Gout       RSD       Raynaud's Disease

3) I am treating this patient under a comphrehensive plan of care for his/her diabetes, Arthritis or Raynaud's disease

4) This patient needs the Ankle/Foot Gauntlet because of their condition

Rx: Ankle/Foot Gauntlet

Physician Name:____________________________ UPIN#________________________

Phone: ( ) __________-_______________        Fax: ( ) ________-_________________

Address:________________________________________________________________
                                                                      City             State              Zip

Attending Physican Signature:_______________________ Date: ____/_____/_______
                                             Original Signature Only - No Stamp

Diabetic Shoes Products Ordered:

One pair extra depth and three (3) pairs of inserts:____________

Product Code:________________                  Mfg: ______Dr._Zen__

Shoe Type:  

                 Lace____ Velcro____ Color____ Size____ Width____ Lycra____ Leather____

                 Men's_____ Women's___

Diabetes, Arthritis, & Raynaud's Disease Product

One each Ankle/Foot Gauntlet:

      Left Foot       Right Foot       Bilateral

    Product Code: 8*232           Mfg: __________________

Print out (CTRL P TO PRINT) and mail or fax form to

Pain Managment Technologies, Inc.
1340 Home Avenue
Building A
Akron, OH 44310

FAX: 888-304-5454