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orthotic consultation questionnaire

You have reached this page because you are confused about the type of orthotic to order for your foot, ankle or leg pain. You are not alone. I realized after a while that in spite of all the information I have tried to include on this site, plus information people have received from their doctors they still may not be able to determine the type of orthotic that they require in order to solve their problem.

LET ME HELP.

On this page is a questionnaire which will allow me to help you. Here is what you have to do:

1. You must pre-pay for the orthotics. I am charging a flat rate of $69.00 for the orthotics and the consultation. This fee does not include shipping and handling. The actual orthotics are still covered under my 60 day, no questions asked, return policy. (the return policy applies to the orthotics only as outlined under each orthotic description; it does not apply to the part of the fee that goes toward the consultation). <>Please note: without pre-payment your questionnaire will not be acted upon.

2. Once you have paid for the orthotics through PayPal which is a very secure means of payment on the internet, you will automatically be redirected to this page to then fill out the questionnaire. Very important, once you make your payment PayPal will issue you a transaction ID#. That number has to be included in the questionnaire in order to confirm that payment has been made.

3. Properly filling out the questionnaire is very important. Tell me everything and anything you think may be of importance. I need to know where it hurts, when it hurts, what makes it worse, what makes it feel better. Describe the pain, is it burning, tingling, radiating, sharp pain, dull pain. How long have you had the pain, is it getting worse? Is this the result of trauma, is it the result of athletics, is it the result of something you do at work? You get the idea. Tell me everything!

If I am unclear on any issue, I will email you and ask for clarification. If after going through your questionnaire, I do not think I can help you, I will refund your total payment.

Based on the information you supply, I will determine the type of orthotic I think will help and we will send them out to you.

It is that simple. To get started simply click the BUY NOW button below. Order RISK FREE

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

E-mail Address*
E-mail Address*

PayPal Transaction ID#*
PayPal Transaction ID#*

Your foot pain diagnosis*
Your foot pain diagnosis*

Who made this diagnosis?*
Who made this diagnosis?*

Your age*
Your age*

Your weight*
Your weight*

Your sex*
Your sex*

Your occupation*
Your occupation*

Are you athletic? What is your sport?*
Are you athletic? What is your sport?*

Where are you having pain?*
Where are you having pain?*

How often do you have pain?*
How often do you have pain?*

What type of shoes do you generally wear?*
What type of shoes do you generally wear?*

	casual laced
	sneakers
	work boots
	clogs
	loafers
	dress flats
	pumps
	high heels
	sandals
	flip flops
	orthopedic shoes
	deck/boat shoes
	other

Your shoe size*
Your shoe size*

Tell me everything you can about your pain, when it hurts, what makes it feel better, type of pain, etc*
Tell me everything you can about your pain, when it hurts, what makes it feel better, type of pain, etc*

Please enter the word that you see below.

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