Orthotics & Prosthetics (O/P) Forms

  1. How were you referred to O/P?

Please complete the correct form to consent to treatment.

I was referred to O/P by a Premier Bone & Joint Centers physician or provider:

I was referred to O/P by a provider outside of Premier:

2. Are you/Is the patient getting fitted for custom foot orthotics?

If so, please also review & sign our Payment Policy for Custom Foot Orthoses.

3. Are you the Guardian of a Pediatric O/P Patient?

If you are, please also review & sign our Children’s Foot Orthosis Outgrowth Policy.