Statement of Certifying Physician For Therapeutic Shoes

Patient Name:______________________________________________________

HIC #:___________________________________________________________

I certify that all of the following statements are true:

1) This patient has diabetes mellitus.

2) This patient has one or more of the following conditions (circle all that apply):

1. History of partial or complete amputation of the foot
2. History of previous foot ulceration
3. History of pre-ulcerative callus
4. Peripheral neuropathy with evidence of callus formation
5. Foot deformity
6. Poor circulation

3) I am treating this patient under a comprehensive plan of care for his/her diabetes.

4) This patient needs special shoes (depth or custom-molded shoes) because of his/her diabetes.

Physicinas Signature:_________________________________________________

Date Signed:_______________________________________________________

Physicians Name (printed):____________________________________________

Physicians Address:_________________________________________________

________________________________________________________________

________________________________________________________________

Physician UPIN:___________________________________________________