Brian Wiggen, CO, BOCPO M.

Wes Huskey, BOCPO

North Carolina Office: 107 East Walker St. East Flat Rock, NC 28726 Phone (828) 595-9371 Fax: (828) 595-9373
South Carolina Office: 366 South Pine St. Spartanburg, SC 29302 Phone: (864) 208-1745 Fax: (864) 208-1778

ORTHOTIC/PROSTHETIC REFERRAL FORM: DISPENSING RX

PATIENT NAME: _______________________________________________ DOB: _________________

DIAGNOSIS: _________________________________________________________________________

PLEASE EVALUATE AND TREAT PATIENT WITH THE FOLLOWING DEVICE:

PROSTHETICS *Please circle: Left Right Bilateral
Above Knee (AK) Above Elbow (AE) Prosthetic Supplies
Below Knee (BK) Below Elbow (BE) Other Prosthesis
Partial Foot Hand

ORTHOTICS *Please circle: Left Right Bilateral

Ankle Foot Orthosis (AFO) Knee Orthosis (KO) Spinal Orthosis Upper Extremity Pediatrics
Solid Ankle Hinged TLSO Hand & Wrist Cranial
Free Motion Post-Op/ROM LSO Thumb Spica SureStep UCB
Dorsiflexion Assist Ligament C.A.S.H. Brace Elbow Orthosis Scoliosis Brace
Walker Boot OA Unloader Cervical Collar Shoulder Orthosis
Shoes & Inserts Knee Ankle Foot Orthosis (KAFO) OTHER PRESCRIBED DEVICE:
Diabetic Shoes Stance Control ___________________________________
Diabetic Inserts Locking KAFO ___________________________________
Custom Shoes Free Motion KAFO ___________________________________
Functional Inserts
Physician's Name: ____________________________________________________ NPI: __________________________
Physician’s Signature: _____________________________________________________________ Date: ______________________

Address: ________________________________________________City, State, Zip:______________________________

Phone: _________________________________________ Fax: _______________________________________________
*** PLEASE FAX REFERRAL SHEET WITH PATIENT DEMOGRAPHICS AND WE WILL BE HAPPY TO CONTACT PATIENT FOR
APPOINTMENT.***