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Menu
Preventive Programs
Physicians
MomWell Pregnancy
Pregnancy Benefits Form
MomWell Ordering Page
VTE
What is DVT?
DME/DVT Network
PedWell Details
PedWell Program
Individual Consumer / Patient
How Do I Schedule an Appointment
PedWell Provider/Clinician
PedWell Diabetic Shoe Network
Physician Order Form
Shoe Patient Intake Form
Prosthetics
Providers
What to Expect With Your New Prosthetic
Prosthetic Care & Use
Prosthetic Liner Care
Residual Limb Skin Care
Cleaning & Moisturizing
Common Skin Care Problems
Skin Care Do’s and Don’ts
Amputee Resources
Veteran Services
Custom Socket Gallery
Orthotics
What to Expect With Your New Orthotic
Orthotic Care & Use
AFO Care
Foot Orthoses Care
Fracture Orthosis Care
KAFO Care
Knee Orthosis Care
Shoe Care
UCBL Care
Wrist Hand Orthosis Care
Guidelines for Ankle Foot Orthosis
Diabetic Shoe Care
Guidelines for Skin Care/Diabetic Foot Care
About
News and Updates
Synergy Prosthetics FAQs
Orthotic & Prosthetic Terms
Employee Resources & Forms
New Diabetic Shoe Patient Intake Form
A
PDF
version of this form can be downloaded
here
and sent to info@www.synergydmepos.com
Patient's First Name
MI.
Last Name
Date Of Birth
Gender
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Female
Social Security Number
Patient's Address
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State
Zip
Phone Number
Alternate Phone Number
Email
Is Medicare Your Primary Insurance
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No
Medicare Number
If Not, List Insurance Payer
Primary Insurance ID
Phone #
Secondary Insurance Payer
Secondary Insurance ID
Phone #
PHYSICIAN TREATING (MD OR DO)
Physician's Name
Phone
Fax
Email
Physician's Address
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I authorize Synergy Prosthetics to contact my Physician to obtain a prescription for therapeutic shoes/inserts, my insurance company to verify my benefits, and to contact me or my caregiver to discuss my order.
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