Healthcare Orthotics Consent Form

Healthcare Orthotics Consent Form

Patient Information

Patient Name:    Date of Birth:

Gender:    Shoe Size:

Insurance Information

Medical History

Orthotic Evaluation, Fitting, and Device Information

Practitioner/Clinic:    Date of Evaluation:

Description of Service: The practitioner has recommended the provision of custom or pre-fabricated foot orthotic device(s) to address biomechanical, structural, or symptomatic conditions. Services to be provided may include clinical assessment, casting/scanning, device fabrication, fitting, and subsequent adjustments.

Risks, Complications, and Limitations

I understand that the provision and use of orthotic devices involves certain risks and limitations, which may include but are not limited to:

• Initial discomfort, skin irritation, blisters, pressure points, or soreness.
• Requirement for multiple adjustments, modifications, or replacements to achieve comfort or clinical goals.
• Failure to relieve symptoms completely; symptoms may persist or recur.
• Potential change in gait or balance when first using orthotics, with small risk of falls.
• Device wear or failure requiring repair or replacement; cosmetic or footwear limitations.

No guarantee is made that the orthotic device will eliminate pain or prevent future injury. The patient acknowledges that compliance with instructions and follow-up is necessary for optimal outcome.

Alternatives

Reasonable alternatives to orthotic therapy were discussed, including:

No orthotics / activity modification
Over-the-counter insoles or shoe modifications
Physical therapy / exercise program
Surgical intervention when clinically indicated

Patient Responsibilities and Follow-Up

The patient agrees to follow wearing and care instructions, attend scheduled follow-up visits for fit and function assessment, and promptly report adverse effects or device failures. Failure to follow instructions may increase risk of complications and may void certain manufacturer or clinic warranties.

Confidentiality and Use of Health Information

I acknowledge that my health information related to this evaluation, device fabrication, and billing may be used and disclosed for clinical care, device manufacture, quality assurance, and payment purposes. Information disclosed will be the minimum necessary to accomplish the stated purpose.

I acknowledge that I have received and had explained to me the clinic's privacy practices with respect to this treatment.

Authorization for Release of Information (for billing/fabrication)

I authorize the clinic and its agents to release medical information and records as necessary to process insurance claims, to communicate with the device laboratory or manufacturer regarding fabrication and fit, and to coordinate care with other treating providers.

Financial Acknowledgment

I understand that charges may apply for evaluation, molding/scanning, device fabrication, fitting, and adjustments. Insurance coverage is not guaranteed. I agree to be financially responsible for charges not paid by my insurance and to provide accurate insurance information.

I acknowledge financial responsibility for services and understand billing procedures.

Consent and Certification

By signing below, I certify that I have read and understand the information provided in this consent form, that the practitioner has explained the nature and purpose of the orthotic evaluation and device, the risks and benefits, and alternatives. I have had the opportunity to ask questions which have been answered to my satisfaction. I consent to the evaluation, fitting, fabrication, and dispensing of orthotic device(s) as indicated.

I understand that I may withdraw this consent at any time by providing written notice, except to the extent that action has already been taken in reliance on this consent.

Relationship to patient (if signing on behalf of patient):

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