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.
Full Legal Name
Gender (for footwear profile)
Shoe Size (US)
Date of Birth
If Patient is <18 Years Age, Parent/Legal Guardian Name:
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