Customer Information: Company: Name: Address: City, State & Zip Phone #: Email Address: PO Box 4837, Mooresville, NC 28117 Telephone: 704-799-2873 Fax: 704-663-4369 Alternate Fax: 704-664-0226 Patient Registration Form - Orthopedic Footwear & Bracing www.occfitsolutions.com Date of Birth: Insurance Information: Primary Insurance Company Name: Member ID #: Insured's Name: Group #: Date of Birth: Physician Information - Must have approval from your physician Physician Name: Address: Phone Number: Fax 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: D Date:
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 LILIANA (36-42) SHAINA (36-42) JULIA (36-42) WINONA (35-43) Burnished Nubuck Tumbled Leather Milled Nappa Leather Milled Nappa Leather MARCELLE (35-43) Nappa Leather Patent Leather STEFFI (36-42) LISANNE (36-42) Milled/Patent PROFESSIONAL (35-43) Patent (Medium/Wide) Cabrio (Narrow/Med/Wide) Oiled(Medium/Narrow FAWNA (35-43) ALISSA (36-42) FRANNY (36-42) LORALIE (36-42) Milled Nappa Milled Nubuck Milled Nappa Red Burnished Nubuck Burnished Nubuck SAM (36-43) JANE (36-42) Burnished Full Grain PEPPER (36-42) Nappa Leather JOSIE (36-42) Nappa Leather CAMELLIA (35-43) EMMA (36-42) PAISLEY (Slip & Waterproof) Smooth Suede (36-42) Nylon/Leather CORAL (35-43) Patent
LINETTE (36-42) Milled Nappa Red Nubuck Leather WILLA (35-43) ELLIE (36-42) JOY (36-42) Nubuck Leather VOYAGE (6M-11M) VENECIA (4M-12M) EMILINE (4M/N/W - 12M) Tumble Leather EMILY (4.5M/W-12M) MICHELLE (5M/N-12M) Shiny CLARISSA - (4M/N/W-12M) CHANNING (5.0M-10M) DEV (4M-12M) - 2" Heel COCO (5.5-12M/W/EE) Patent CINDEE (5.5-12M/W/EE) FLUTE (4-12N/M/W/EE) w/ Lycra MERRY JANE (5.5-11M/W/EE) Tumbled Leather DAPHNE (35-42) VIGOR (4-12N/M/W/EE) Chestnut PIPER - COMPOSITE TOE (5-10M/W) Dark (5-11M/W) HARRISON 6" - STEEL/SOFT TOE (5-11M/W)
CLEMENTS FREEDA (2 1/4") AVALA (2" Heel) ANETO MOCHO AMERY TOBY II BURR HAVANA (4-13N/M/W) LONDON II (5-13N/M/W/EW) BLACK STRETCH SAN MARINO DREW FUSION (5-13N/M/W/EW) w/ Stretch (5-13N/M/W/EW) White Leather MAYA DREAM FIT (36-42) Stretch - M/W MONACO Dusty Leather SUMMER ALGRIA ERYN Jet Luster KELI (35-44) ELLA (35-42) DAYNA (35-41) ESSENCE (35-42) - M/W - M/W - M/W Jet Luster - M/W
JOSH (41-47) Taupe Milled Nubuck Mahogany Antiqued Calf JUSTIN (41-48) Oiled Nubuck Oiled Nubuck JACKSON (41-47) Mahogany Antiqued Calf OZ - ALLEGRIA (41-48) Tumble OMAHA DECKER BAINBRIDGE FULTON VOYAGER White Leather 7-16 (N/M/W/4W) BOULDER - COMPOSITE TOE ROCKFORD - COMPOSITE TOE TREK Tumbled Leather Tumbled Nubuck Dark Tumbled Dark 8-16 (M/W/4W) 8-16 (M/W/4W) 7 16 (N,M,W 4W) XC4 - STANTON MOC VEN XC4 - BRANNING WINGTIP XC4 - HOLLIS PLAIN TOE BRANNING CAP TOE (7-14) (8-13) (7-12M/XW) (8-13) Tan (7-14) MAHOGANY (8-13) Mahogany (8-13)
CHRIS (7.5-14 M/W/EW) /Grey Grey/ JASON (7.5-14 M/W/EW) Blue Red PERFORMANCE /Grey Metallic Blue/Grey Metallic Red/Grey (6-15 M/W/EW) ENDURANCE PLUS White (6-15 M/W/EW) ** PLEASE INDICATE TOE PREFERENCE - SOFT, STEEL OR COMPOSITE LEGEND - Composite/Soft Toe DURASHOCKS SR - Composite/Soft (7-14 M/EW) (6-15 M/EW) ANTHEM - Steel/Soft Toe DURBIN - Steel/Soft (7-14 M/EW) (7-14 M/EW) RAIDER - Steel/Soft Toe I-90 EPX CARBONMAX BOOT - 6" only (7-15 M/EW) ( 7-14 M/EW) KHYBER - 6" or 8" ( 3-14 M/W) CHROME - 6" or 8" Waterproof - Composite Toe ( 6-15 M/W) JETSTREAM 2 CARBONMAX RUSH ESD DELTA 6" - Safety Toe - Safety Toe ( 7-14 M/EW) (6-14 M/EW) KHYBER HOT WEATHER
Circle area of that experiences pain/discomfort and explain below: SPECIFTY RIGHT OR LEFT Back Support Products: Lumbamed Plus Postural Control Brace Cincher Back Support Ankle & Foot Supports: Maternity Support Achilles Tendon Support Knee Supports: Ankle Support Ankle Brace Wrist Supports: Plantar Fasciitis Night Boot Genumedi Knee Genumedi Pro Knee Manumed Active Elbow Support: Orthopedic Wrist Brace Epicomed Elbow