REFERRAL FORM - littleSTEPS Orthotics and Gait Plates
You must enter a medically validated referral code to place an order and get a 10% discount. If you do not have a referral code download the attached pdf form and have it signed by a medical practitioner, which can include MD, DPM, Chiro, Physical Therapist, etc. This typically is accomplished via email and does not require an office visit.
Have the practitioner sign and email you the completed form. Forward the signed form to firstname.lastname@example.org
You will be sent the referral code by email. This code will also discount the online price by 10%. By retaining a copy of the form you can use it for future orders and receive a 10% discount for those orders.
For questions call 203-725-6179