Download our Diabetic Patient Packet

Download our diabetic packet using the link below. You can fill out the form offline and bring the completed and signed copy with you to your appointment.

Tierney Diabetic Packet

TIERNEY O&P DIABETIC FORM

IMPORTANT : We will obtain an office note from both your diabetes doctor and (or) the doctor who examines your feet (i.e. podiatrist, wound care specialist). These notes must be dated within the last 4 months. If the visit was later than 4 months, you will need a follow up appointment. The paperwork we request must be signed and co-signed by the MD/DO who supervises your diabetes care.

Full Name
Date Of Birth
Address
Home Phone
Cell Number
Primary Insurance (Company & Member ID)
Secondary Insurance (Company & Member ID)
Do you have Diabetes? (If not, you can qualify for "Self Pay")
Yes
No
Diabetes Doctor - If you see a Diabetes Doctor (Endocrinologist), list them first
Current Phone
Current Fax
Foot Care Doctor - Podiatrist or Wound Care Doctor or Primary Care Doctor
Current Phone
Current Fax
Check any applicable MCR required foot conditions
Poor Circulation
Amputation
Callus w/ Neuropathy
Pre-ulcerative Callus
Foot Ulcer
Foot Deformities
Unsure
Send
Send
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Since 2014, Tierney Orthotics and Prosthetics has become the Winston-Salem, North Carolina area’s preferred source for orthotics, prosthetics, diabetic footwear, mastectomy prosthetics, and shoe inserts.