STATEMENT OF CERTIFYING PHYSICIAN

PATIENT NAME:______________________________________________________

HIC #:______________________________________________________________

1) The patient has diabetes mellitus.

2) This patient has one or more of the following conditions:

a. History of partial or complete amputation of the foot.

b. History of previous foot ulceration.

c. History of pre-ulcerative callus.

d.  Peripheral Neuropathy with evidence of callus formation.

e. Foot deformity.

f. Poor circulation.

3) I am treating this patient under a comprehensive plan of care for his/her

    diabetes.

4) This patient needs special shoes and or inserts because of his/her diabetes.

Physician Signature:_________________________________Date:_____________

Physician name:______________________________________________________

(printed - MUST BE AN M.D. OR D.O.)

Address:____________________________________________________________

___________________________________________________________________

Physician UPIN:_______________________________________________________