Schedule an appointment! 281.395. FEET (3338)

Your Total Foot Care Specialist

Serving Katy, West Houston, Cypress, Memorial Piney Point and Galleria, and surrounding communities in Texas

Home
Podiatrist
Foot Conditions
Podiatry Services
Treatment Options
Patient Resources
Tranquility Med Nail Spa
- Nail Spa Services
Locations
Contact Us
- Request an Appointment
Blog
My Account

Remember Me

Katy Appointment Request Form

Home
Katy Appointment Request Form

Katy Appointment Request FormAlice Luu2017-10-06T21:17:25+00:00

Katy Location Appointment Request Form

First Name *
Last Name *
Are you a new patient? *
YesNo
Email *
Address *
City *
State *
Zipcode *
Phone *
Birthday- Must be in MM/DD/YYYY format *
How did you hear about us? *If referred by a physician, please enter physician's name.
Insurance Carrier *
Group *
Member ID *
Claims Address *
City *
State *
Zipcode *
Preferred Day *
Preferred Time : *
Reason for your visit *
Height *
Weight *
Medical History: Allergies *
Please select all that apply:No known allergiesAdhesive tapeLocal AnestheticsAspirinPenicillinIodine / ShellfishCodeineDemerolFood AllergiesOther
Please list other allergies:
Medications *
Please list all medications you are currently taking. If none, please enter "None".
Medical History *
Please check all that apply:NoneBlood pressureCirculatory ProblemsDiabetesLocal anestheticOther
Other Medical History
Please list all other Medical History you may have:
A1C Reading *
If you are diabetic, what was your last hemoglobin A1c reading?
Surgical History *
Have you had any major surgeries? How many? Which ones? (only in the last 10 years). If none, please enter "None".
Smoking Status *
Are you currently smoking?YesNo
Flu Shot *
Have you had the flu shot for this season?YesNot Applicable
When was your last flu shot? (Go to the next question if not applicable).
Pneumonia shot *
If you are over 65, have you had a pneumonia shot?YesNoN/A
When was your last pneumonia shot? (Go to the next question if not applicable).
What is your shoe size? *
Please list your primary care doctor *
What is the address of the preferred pharmacy location to pick up your medication? *

Verification

Please enter any two digitsExample: 12
This box is for spam protection - please leave it blank

Your Total Foot Care Specialist

23230 Red River Drive Katy, TX 77494 - URL of Map
19255 Park Row Dr, Ste. 202 Houston, TX 77084 - URL of Map
27700 NW Freeway Suite #310 Cypress, TX 77433 - URL of Map

2500 Fondren Rd #255 Houston, TX 77063 - URL of Map

Phone: 281-395-3338