2701 NW Vaughn Street, Suite 424, Portland, OR 97210 (503) 243-2699

New Patients

Please print and bring these completed forms to your appointment or arrive 15 minutes early to fill them out in the office.

*Return patients who have not been seen in 3+ years are required by Oregon law to be re-admitted as a “New Patient.”

Medicare Agreement

This agreement is for all patients who are insured under Medicare. This form must be completed in order to provide treatment and states that the patient understands they will not be reimbursed by Medicare.

Remote Consultation

The following information is required and must be submitted before scheduling a consultation.

  • All remote consult forms
  • Preferred method of contact: (choose one) Skype Facetime or Phone
    Username and/or phone number:
  • Backup method of contact: (choose one) Skype Facetime or Phone
    Username and/or phone number:
  • At least one top-view picture of your feet while standing on insoles or liners pulled out of your most-used footwear.

*Optional: If you own Correct Toes, please include a picture of them on your feet.

*Optional: If you have recent (past 3 years) X-Rays or MRIs of your feet or ankles, we ask that you send those images on a disc via snail mail. Please make sure to include the report.

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