Custom Orthotics - Gait Analysis
Custom Orthotics are a medical device designed to support the foot and ankle resulting in improved biomechanics, pressure distribution and shock absorption. Custom Orthotics can alter muscle activation and joint biomechanics along the kinematic chain during gait, but they do not change the underlying structure of the foot.

I acknowledge and confirm that the information provided on this form is true. I consent to allow the health practitioner to collect relevant information and perform clinical exams and tests to provide a diagnosis and treatment plan. I authorise Credit Valley Wellness Centre to communicate with me via telephone and email for information related to my case.

Dr. Previn Panwar, DC
Certified Gait Analysis, Custom Orthotics Design and Dispensing
Credit Valley Wellness Centre
209-2000 Credit Valley Road, Mississauga, ON L5M 4N4
Mobile/Text: 416-897-9355
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Email *
Full Legal Name *
Gender (for footwear profile) *
Weight (lbs) *
Shoe Size (US) *
Date of Birth *
Telephone (###-###-####) *
If Patient is <18 Years Age, Parent/Legal Guardian Name:
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