Come for a FREE foot screening and fitting with or STEP foot orthotics
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1 Ankle or Instability Are you struggling with: Are your kids struggling with: Poor coordination littlesteps QUADRA Call for an appointment or for more information Come for a FREE foot screening and fitting with or STEP foot orthotics A d d r e s s, c i t y, s t a t e, w e b s i t e a n d e m a i l
2 Ankle or Instability Are you struggling with: Are your kids struggling with: Poor coordination Call for an appointment or for more information Come for a FREE foot screening littlesteps QUADRA and fitting with or STEP foot orthotics A d d r e s s, c i t y, s t a t e, w e b s i t e a n d e m a i l Your Date and Your Date and Your Date and Your Date and Your Date and Your Date and Your Date and Your Date and
3 Are you struggling with: Ankle or Instability Come for a FREE foot screening and fitting with littlesteps or QUADRASTEP foot orthotics ages 1-17 Are your kids struggling with: Poor coordination Call for an appointment or for more information A d d r e s s, c i t y, s t a t e, w e b s i t e a n d e m a i l FALL FAMILY FOOT SCREENING CLINIC Are you struggling with: Ankle or Instability Come for a FREE foot screening and fitting with littlesteps or QUADRASTEP foot orthotics ages 1-17 Are your kids struggling with: Poor coordination Call for an appointment or for more information A d d r e s s, c i t y, s t a t e, w e b s i t e a n d e m a i l
4 Refer Patients to our upcoming Fall Family Foot Screening Clinic The Clinic Includes: FREE foot exam/gait analysis For Adults and Kids ages 1-17 Ankle or Instability Test fitting with prefab orthotics (QUADRASTEPS or littlesteps) Recommendations for future treatment Send adults to our clinic if they are experiencing: Poor coordination Send kids to our clinic if they are experiencing: Adults or parents interested in bringing their kids can register by calling or online at A d d r e s s, c i t y, s t a t e, w e b s i t e a n d e m a i l
5 SIGN ME UP FOR THE FALL FAMILY FOOT SCREENING CLINIC for Adults and Kids ages 1-17 Name Adult/Child Shoe Size (for confirmation) Phone
6 REGISTRATION RECEIPT BRING THIS TO THE CLINIC AND GET SPECIAL PRICES ON littlesteps or QUADRASTEP foot orthotics Tell your friends! A d d r e s s, c i t y, s t a t e, w e b s i t e a n d e m a i l FALL FAMILY FOOT SCREENING CLINIC REGISTRATION RECEIPT BRING THIS TO THE CLINIC AND GET SPECIAL PRICES ON littlesteps or QUADRASTEP foot orthotics Tell your friends! A d d r e s s, c i t y, s t a t e, w e b s i t e a n d e m a i l
7 CLINIC REGISTRATION FORM Patient s Name: Date of Birth: Home Phone: SS#: Parent Phone: Street Address: City: State: Zip: Parent Address: For Future Specials/Refurbishment Reminders* Person to contact in case of emergency: Phone: (Closest relative not living with you) Was this due to an accident? Y N Auto Work Other Where were you injured? Date of Injury: Height: Weight: Shoe Size: Shoe Style: Primary Care Physician: Phone: Referring Physician: Phone: Allergies: Current Medications: How did you hear about us?: 1Mailer 1Poster 1Referred by a friend 1Referred by a practitioner 1Website 1 Name of website/practitioner: Patient or Parent/Guardian Signature: Date:
8 Call for an appointment or for more information The Clinic Includes: FREE foot exam/ gait analysis Test fitting with prefab orthotics (QUADRASTEPS or littlesteps) Recommendations for future treatment Website Graphic
Come for a FREE foot screening
SPRING FOOT SCREENING CLINIC Runner's Knee Stress Fractures Are your kids struggling with: Come for a FREE foot screening Are you struggling with: littlesteps and fitting with or QUADRASTEP foot orthotics
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