APPOINTMENT REQUEST

Is there a specific date that you would prefer?
Desired Year200820092010201120122013- Desired Month JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember- Desired Day 01020304050607080910111213141516171819202122232425262728293031
 

Is there a specific time that you would prefer?
Desired Hour010203040506070809101112: Desired Minute 00153045Desired AM/PM AMPM
 

What day of the week would you like to come in?
Preferred DayAnyMondayTuesdayWednesdayThursdayFridaySaturdaySunday
 

What time of day do you prefer?
Preferred Time of Day AnyMorningLunchAfternoon
 

Full Name

 

Email Address

 

Phone Number

 

Please describe the nature of your appointment:
Comments

1. Have you ever been diagnosed with diabetes?
Yes
No


2. Are your feet cold, blue, swollen, or have you ever been told you have a circulation problem?
Yes
No


3. Do you have feelings of electrical shock, or bugs crawling on your legs? Do you have numb feet or legs?
Yes
No


4. Do you have bumps on the sides of your big or little toes?
Yes
No


5. Do you have heel or arch pain first thing in the morning or after you have been resting?
Yes
No


6. Do you have thick, black, yellow, crumbly, or ugly nails?
Yes
No


7. Do you have pain in the balls of your feet?
Yes
No


8. Do you have calloused, scaly, or cracked feet?
Yes
No


9. Do you get ingrown toenails?
Yes
No


10. Do you have sores on your feet that are slow healing?
Yes
No