Diabetic Shoes

Enjoy a personalized fit you will love.

Kohll's Rx provides a large selection of Diabetic shoes.

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Name*
First Last
Phone*
Email*
Insurance Information
Insurance provider:*
ID Number or Medicare/Medicaid ID:*
Medical Information
Name of physician responsible for diabetes care:*
Have you had an in-person foot exam in the last 5 months?*
- YES
- NO
Date of last in person foot exam:*
MM slash DD slash YYYY
NOTE: A foot exam within the last 5 months is required for diabetic shoes to be covered by insurance. Please continue to fill out this form and contact Kohll’s after your next appointment.
Which of the following conditions apply to you?*
(Select all that apply)
- Poor circulation in either foot
- Evidence of callus formation of either foot
- Foot deformity of either foot
- History of pre-ulcerative calluses of either foot
- History of foot ulceration in either foot
- Previous amputation of either foot or part of either foot
Have you received diabetes shoes from Kohll’s in the past?*
- YES
- NO
SMS / Text Permissions*
- Yes, text me diabetic shoe information.
- No, do not text me.
Email Permissions*
- Yes, send me exclusive marketing e-mails.
- No, do not send me marketing e-mails.
Comments
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