Vienna Medical 1-800-489-8165 Fax completed form to 1-800-602-2900

Statement of Certifying Physician for Therapeutic Shoes

Patient name: ________________________________________________ Patient phone:______________________________

Hic # ________________________________________________________

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.

Y ______ N ______

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

Physician signature:
_______________________________________________

Date signed:
_______________________________________________

Physician name (printed):
_______________________________________________

Physician address and phone number:
________________________________________________

Physician UPIN: ___________________________________