Allied Health Professionals
Please call 1-800-220-6670 for referrals, educational opportunities, or to schedule an in-service.

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Name:

Please Note: The fields indicated in bold are required. All information in this form shall be held in the strictest confidence. It will be used soley for the purpose of sending you information about Ultraflex® braces on the information you provide us. With your permission, it will be forwarded to an Ultraflex provider to contact you for a potential evaluation.
Name:
Address:

Phone number:
Fax number:
Email address:
Age:
Medical Condition:
What are your medical conditions or recent injuries that you believe may be helped by Ultraflex® braces?
Do you wear orthotic braces now?	yes no
If yes, may we contact the person or facility that made them?	yes no
Do you see a physical or occupational therapist now?	yes no
May we contact them?	yes no
If you think you need leg braces, are you walking independantly now?	yes no
Any additional comments?
How would you like us to contact you?	email phone mail