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West Houston Appointment Request Form

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West Houston Appointment Request Form

West Houston Appointment Request FormAlice Luu2017-10-06T21:32:01+00:00

West Houston 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? (Please enter a value or NA if not applicable.)
Surgical History *
Have you had any major surgeries? How many? Which ones? (only in the last 10 years). If none, please enter "None".
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).
Smoking Status *
Are you currently smoking?YesNo
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

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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