Today's Date

Full Name

Street Address

City

State

Country

Postal code

Are you happy to be contacted regarding our future promotions & product updates?

Yes

No

Are you happy to be contacted via phone/text/email about your purchase?

Yes

No

Phone

Email

How did you hear about us?

What do you hope to accomplish today at Foot Solutions?

Do you currently wear orthotics or inserts?

YES

NO

If YES, for how long?

Were you referred to Foot Solutions by your doctor/other medical practitioner?

YES

NO

If YES, please provide their name/location

Do you consent to us contacting them on your behalf, if we deem it necessary in order for us to provide the best care/follow up treatment for you?

YES

NO

Leg Length+/-

Left Leg

Right Leg

Please specify other neuromuscular conditions

Do you have any other foot pain, allergies, or relevant medical information you feel we should know? (If YES, please type below)

As trained Pedorthists, Foot Solutions will recommend the appropriate size & footwear for you and your specific foot condition. As part of our services, we may need to make in store adjustments to your shoes and custom inserts. Foot Solutions Pedorthists DO NOT diagnose foot disorders. We provide expertise in providing the best solutions to combat common foot issues. We reserve the right to refuse treatment without a doctor’s prescription, if we deem your condition warrants medical attention.

Eligibility Declaration (please see HMRC Notice 701/7 for more information).

I have read the above disclosure by Foot Solutions. I have a disabling or chronic condition; I am receiving the following goods which are being supplied to me for domestic or my personal use; and I claim relief from value added tax: Please tick

By signing this form, you explicitly consent to the processing of your personal data by Foot Solutions in the performance of its contract with you & to provide you with marketing communication (if you have consented to

marketing communication). Please read our Privacy Policy (instore, or on our website) for more information on how we process your data & your rights.

Signature (parent/guardian if under 18):

Date

Signature

Clear

Supplier Declaration:

Please note there are penalties for making false declarations.

Supplier:

I, on behalf of Foot Solutions of 34 Royal Parade, Plymouth, Devon, PL1 1DU am supplying to the person named above the following goods:

(see POS customer file relating to date below) for the personal use of the disabled person.

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