Foot Clinic - Intake Form

Foot Clinic - Intake form

Streamline Your Appointment Process

Our Foot Clinic Intake Form, designed to simplify your appointment process and ensure personalized care. This form helps us gather essential information about your foot health history and concerns, enabling our expert team to tailor treatments and recommendations to meet your individual needs. Your comfort and well-being are our priorities at every step of your journey with us

Please Contact Us

Please fill out this form to contact us or to book an appointment. You do not need a doctor’s prescription to visit us.

New Patient Questionnaire

Date

Name: (Mr, Mrs, Miss, Ms):

Address:

City:

Postal code:

Phone. Home:

Work:

Cell

DOB(mm/dd/yyyy)

Sex:

M F

Your Insurance Company

Policy or Contract No.:

Certificate or I.D. No:

Employer Name:

Work Address:

City:

Postal Code:

Occupation:

Marital Status:

How did you hear about our clinic:

Please tell us why you are here:

Foot Pain Back Pain Knee Pain Ankle Pain

If patient is under 16 years of age or mentally challenged a parent or guardian must sign below

I am the parent/guardian of the above named patient and I give my consent for his examination and treatment.