Orthopedic Shoe Modifications & Lifts

Orthopedic Modification Assessment

Tell us about the footwear and modification you need. Virginia Shoe Clinic will review your request and contact you regarding next steps. Please do not submit medical records or confidential health information through this form.

First Name*

Last Name*

Email*

Phone Number*

Preferred Contact Method*

What type of modification are you requesting?*

Which shoe(s) needs modification?*

Do you already have the footwear?*

Footwear Brand

Footwear Model

Shoe Size

Width

Would you like help selecting footwear for your modification?*

Do you already have provider instructions for the modification?*

Provider / Referral Information

How would you like to send us your footwear?*

Is this your first pair, or do you need another pair modified?*

Describe the footwear or service you are looking for. Do not include medical records, diagnosis information, or confidential health information.