Orthotic Warranty Form – Fill Out and Use This PDF

ENROLLMENT in the biomechanical Services’: orthotic warranty program will provide for repair or replacement of the orthoses made for:

account name:

patient name:		orthotic no.:

THE BENEFITS of this warranty program take effect once we receive your completed enrollment

form and payment. the coverage period is for two years from that date. the molds used to fabricate your orthoses will be stored for two years, beginning on your conirmed enrollment date.

biomechanical Services will notify your health care provider of your enrollment. you must enroll within four months of the date printed on this form (see below), beyond that, your foot molds are not available for extended storage.

ADJUSTMENTS, REPAIRS AND REPLACEMENTS will be handled through the prescribing practitioner only, as they will have the most complete records of those indications that determined

techniques and components originally applied when fabricating your orthotics. biomechanical

Services will make any modiication prescribed by your health care provider, at no charge, under this program. if your orthotics break, and are determined to be irrepairable, another pair will be made, at no charge, once the devices are returned to our laboratory for evaluation. repaired or replacement orthotics will be returned to your health care provider, noted above, unless other arrangements are made in advance.

LOST OR STOLEN orthotics should be reported to the prescribing practitioner. there will be a

$27.50 replacement charge per device ($55.00 per pair), to fabricate each new orthotic device.

Two devices (or one pair) may be replaced per enrollment period. Adjustment and repair beneits automatically transfer to replacement devices. your health care provider will make the necessary arrangements for any replacement orthoses.

CHILDREN seventeen (17) years of age and younger who have outgrown their orthoses may have one pair of devices replaced during the coverage period, at no charge, if they were of eligible age

at the time of enrollment. new impression molds will be required for new orthotic devices being replaced due to outgrowth, for accuracy in it of larger feet.

ORTHOTIC WARRANTY ENROLLMENT FORM

RETURN THIS PORTION WITH YOUR PAYMENT

orthotic number:

date:

name

address

city, State, Zip

telephone

credit card #

exp. date

card code #

attending health care provider

name

address

city, State, Zip

telephone

encloSed iS my check or credit card information for payment of $60.00, pleaSe accept my completed enrollment application. enroll me in the biomechanical ServiceS extended warranty program.

Signature