HOW CAN WE HELP?

Name *

First Name

Last Name

Phone

If you would like us to start collecting the necessary documentation for your shoes and inserts, please provide us with your best contact information as we will need to collect your date of birth and insurance ID.

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Have you had shoes/inserts/brace in the past? *

Yes, from Crary Shoes

Yes, from another provider

No

Qualifying condition in addition to your diabetes... *

You must have at least one in order to qualify for insurance payment Please select all that apply

History of a partial or complete foot amputation

History of previous foot ulceration or current ulcer

History of a pre-ulcerative callus

Peripheral neuropathy with evidence of callus formation

Foot deformity (hammertoes, charcot, bunion, etc.)

Poor circulation

None of the above (you do not qualify)

Are you seeing a podiatrist (foot doctor)? *

Yes, but I'm also seeing a primary care provider and/or endocrinologist

Yes, and I am seeing no other doctors

No, I just have a primary care provider.