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Call Today 281.395.FEET (3338) 23230 Red River Drive Katy, TX 77494
Open Hours
Mon 8:30 – 5:00 pm Fri 8:30 – 3:00 pm, Sunday: CLOSED

Galleria Appointment Request Form

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Demographics/insurance information :

First Name*:


Last Name*:


Are you a new patient?*:
 Yes No


Address*:


Email*:


Best contact number*:


Date of Birth (Enter in MM/DD/YYYY)*:


How did you hear about us?*:

If referred by a physician, please enter physician's name.


Who is your primary care doctor?*:


What is the address of your preferred pharmacy to pick up your medication?*:


Insurance Carrier:


Group:


Member ID:


Claims Address:


Reason for your visit*:


Height*:



Weight*:


Medical History:

Allergies (Please select all that apply)*:
 None Known Allergies
 Adhesive Tape
 Local Anesthetics
 Aspirin
 Penicillin
 Iodine / Shellfish
 Codeine
 Demerol
 Food Allergies
 Other


Please list 'Other' allergies:


Please list all medications you are currently taking. If none, enter NONE*:


Medical History - Please check all that apply*:
 None
 Blood pressure
 Circulatory Problems
 Diabetes
 Local anesthetic
 Other


Please list all Medical History you have. If none, enter NONE*:


If you are diabetic, what is your last hemoglobin A1C reading? (Enter N/A if not applicable)*:


Please list all major surgeries you've had in last 10 years. (If none, enter NONE.)*:


Have you had the flu shot this season?*:


When was your last flu shot? If not applicable, enter NA*:


Pneumonia shot – If you are over 65, have you had a pneumonia shot?*:


When was your last Pneumonia shot? (If not applicable, enter NA)*:


Are you currently smoking?*:


What is your shoe size?*: