Phone: 412-787-6340

Fax: 412-787-6343

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216 Summit Park Dr

Pittsburgh, PA 15275

Mon-Fri    10-8

Saturday  10-6

Sunday    12-5

© 2019 SANALJON SPECIALTY FOOTWEAR

forms

Needs to be completed before coming for your scheduled diabetic shoe appointment

Needs to be completed before coming for your scheduled orthotics appointment

Prescription form for doctor to fill out for stockings

Prescription form for doctor to fill out for shoes & inserts

Certificate of Medical Necessity for diabetics to be filled out by doctor

Please complete and return once all services have been completed