" I certify that all of the following statements are true":

This patient has diabetes mellitus
This patient has one or more of the following conditions:

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

I am treating this patient under a comprehensive plan of care for his/her diabetes. This patient needs special shoes and/or inserts because of his/her diabetes.

 

 

Doctors Signature ______________________Date________

Doctors Name _____________________________________

Phone # __________________________________________

Address __________________________________________

City, State, Zip ____________________________________