Brace Inquiry
Form

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Brace form for Booked Patients.

"*" indicates required fields

This field is for validation purposes and should be left unchanged.
MM slash DD slash YYYY
Are you an Existing Client?**
Name*
Side of injury**
Were you referred to us?**
I authorise Okaped to send treatment notes and product information to medical professional who referred me or my family physician.*
I consent to have an Okaped staff member asses my needs for an appropriate product. This may include but is not limited to the following: range of motion testing, palpation of the painful area, resisted strength testing, visual and/or video analysis of movement patterns and physical measurements to determine product sizing or custom fabrication.*
* Please let your clinician know if you have a Latex allergy so they may direct you to a Latex free option if available.

3rd Party Billing: Only fill in if applicable.

Written preauthorization from the funding agency is required before we can dispense any product.
Please select an agency if you have authorization for us to bill them.
I authorise Okaped to send treatment notes and product information to the agency if requested.