Non-Surgical Bunion Treatment Guidelines

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Patient Name: _________________________________ (Please Print)

Date: __________________

Please read and initial next to each line. By initialing next to each line, you are indicating that you understand and agree to adhere to the following Bunion Treatment guidelines:

______ I agree to perform my exercises and/or walking re-education, as instructed by Dr. Levingston, for a minimum of 20-minutes per day (10 solid minutes each set) for the duration of my 10-session bunion treatment.
______ I agree to limit and/or abstain from drinking alcohol or coffee during duration of the treatment period.
______ I will continue to perform my instructed exercises at home as a form of maintenance post bunion treatment to continue to strengthen and maintain my Hallux Valgus correction attained from the treatment with Dr. Levingston.
______ I agree not to wear tight fitting shoes, high heels, or sandals for the duration of my 10-session bunion treatment. I understand that not following this guideline could prevent me from receiving the full benefit of my bunion therapy and prevent me from meeting my intended goals.
______ I agree to limit tight fitting shoes, high heels, or sandals post bunion treatment. I understand that not following this guideline could potentially reverse any Hallux Valgus correction attained during my bunion treatment.
______ I agree to stay hydrated by drinking the recommended amount of water:
Recommended Daily Water Intake: ______ Ounces / ______ glasses of water

Patient Signature: ________________________________

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