Brace Inquiry

Brace form for Booked Patients.

"*" indicates required fields

MM slash DD slash YYYY
Are you an Existing Client?**
Side of injury**
Were you referred to us?**
* 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 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.
This field is for validation purposes and should be left unchanged.