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Which condition is your child experiencing that you believe orthotics could help with?

A few questions about your child’s toe walking…

Has your child used orthotics before?

Yes No

Has your child been officially diagnosed by a doctor?

Yes No

Is your child experiencing discomfort, if so, where?

Heel Arch Forefoot Ankle Calf All Over No Pain

Is your child able to touch heels to ground?

Yes No

How old is your child?

How long has your child been toe walking? (years)

What is your child’s shoe size?

Your Name

Your Email

Your Phone

Preferred method of contact

Phone Text Email

How did you find us?

Google Search Facebook YouTube Recommendation by Friend or Professional Other

A few questions about your child’s flat feet condition…

Has your child used orthotics before?

Yes No

Indicate if your child has any of the following:

Mid foot Pain is on instep arch Fatigue in the leg Discomfort when walk or run Hard to stand for long periods of time

Has your child been officially diagnosed by a doctor?

Yes No

Is your child experiencing discomfort, if so, where?

Heel Arch Forefoot Ankle Calf All Over No Pain

Does your child play sports?

Yes No

How old is your child?

How long has your child had symptoms of flat feet?

What is your child’s shoe size?

Your Name

Your Email

Your Phone

Preferred method of contact

Phone Text Email

How did you find us?

Google Search Facebook YouTube Recommendation by Friend or Professional Other

A few questions about your child’s heel pain…

Has your child used orthotics before?

Yes No

Indicate if your child has any of the following

Tenderness or sharp heel pain Discomfort during and after athletic activities Awkward walking on sides or balls of feet Discomfort when sides of heels are squeezed Limping None of Above

Has your child been officially diagnosed by a doctor?

Yes No

Is your child experiencing discomfort, if so, where?

Heel Arch Forefoot Ankle Calf All Over No Pain

Does your child play sports?

Yes No

How old is your child?

How long has your child been having heel pain?

What is your child’s shoe size?

Your Name

Your Email

Your Phone

Preferred method of contact

Phone Text Email

How did you find us?

Google Search Facebook YouTube Recommendation by Friend or Professional Other