Patient Packet

16520 Harbor Blvd., Ste. G, Fountain Valley CA 92708 Ph: (714) 210-1298 Fax: (714) 210-1336

2151 N. Harbor Blvd. Ste. 1200 Fullerton CA 92835 Ph: (714) 871-9960 Fax: (714) 871-9965

3650 E. South St. Ste. 110B Lakewood CA 90712 Ph: (562) 206-8025 Fax: (562) 353-8060

25982 Pala Dr., Ste. 100, Mission Viejo CA 92691 Ph: (949) 770-7331 Fax: (949) 770-8331

351 Hospital Road, Ste. 106, Newport Beach CA 92663 Ph: (949) 722-7101 Fax: (949) 722-7120

623 N. Main Street, Orange CA 92868 Ph: (714) 937-1998 Fax: (714) 937-1994

14450 Hoover St., Westminster CA 92683 Ph: (714) 373-9888 Fax: (714) 373-9890

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For Office Use Only

Fountain Orthotics & Prosthetics is requesting the following documents:

Most recent notes

Notes from office visit on

Diabetic follow-up, including labs

Other

Notes

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