Full Name

Street Address

City

State

Country

Postal code

Phone

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).

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):

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.