Urgent, in Person, Orthotic & Prosthetic Care Acknowledgement Form  

Based on the orders of the Chief Medical Officer of Health, the Government of Alberta. Orthotic and prosthetic services can be provided if a patient’s situation is considered urgent. The Government of Alberta is trying to limit non-essential close interactions in the community in an effort to prevent the spread of COVID-19, while at the same time keeping people out of emergency departments for services that regulated health professionals can provide in the community. Orthotic and prosthetic services in are urgent if the following criteria has been met:  

All boxes must be checked to qualify for an urgent, in person orthotic/prosthetic appointment.  

☐ Services cannot be provided using an alternate form of delivery, such as telerehabilitation.  

☐ The inability to initiate in-person care or the withdrawal of care, would lead to serious or imminent harm. 

☐ In the absence of orthotic or prosthetic services, my condition may require health-care services in an emergency department setting (e.g., severe pain requiring physician intervention or prescription medication to manage that pain). 

I confirm that I have read, understand and agree that I fit the above criteria for urgent orthotist services.