Please fill out this form prior to your visit!
Complete this form today to authorize the transfer of your medical records from your existing medical provider. Thank you!
Please release my protected health information for the purpose of orthotics evaluation and treatment to:
My Foot Rx • 1706 York Street, Suite 3 • Bloomer, WI 54724
Phone: (715) 568-1500 • Fax: (715) 568-1501
Please type your first and last name
I understand that checking this box constitutes a legal signature confirming that I authorize the release of my medical records to the facility listed above. *