New Patient
Appointment Form

Completion of this form will ensure a callback within 2 weeks from our office.

Patient Name

First Name

Last Name

Gender

Date of Birth

YYYY

Social Security Number

Address

Please add apartment number and/or gate code.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Gate code

Phone

(###)

###

####

Primary Insurance

Policy ID Number

Do you have a Secondary Insurance?

Secondary Insurance

Secondary Insurance ID

How urgent would you like to be seen?

Will it include treatments of skin and nail?

Have you seen a Podiatrist within the last 61 days?

If Yes, are you looking for a second opinion?

SMS Text Message

I agree to receive text messages from 3Toe1 Foot Doctor at the phone number provided. By checking this box, I consent to receive text messages related to my care and services from 3Toe1 Foot Doctor. Message and data rates may apply. I understand that I can opt-out at any time by texting STOP or UNSUBSCRIBE to +1 (760) 456-5575. For help, text HELP or contact us at www.3toe1footdoctor.com.

Yes, I agree

No, I do not agree

Privacy Policy

Data Sharing

Customer data is not shared with 3rd parties for promotional or marketing purposes.

Mobile opt-in and consent are never shared with anyone for any purpose. Any information sharing that may be mentioned elsewhere in this policy excludes mobile opt-in data.

Messaging Terms and Conditions

By providing your phone number and agreeing to receive texts, you consent to receive text messages from 3Toe1 Foot Doctor, from 760-456-5575 regarding customer care. Consent is not a condition of purchase. Message frequency varies. Message & data rates may apply. You can reply STOP or UNSUBSCRIBE to unsubscribe at any time or HELP for assistance. You can also contact us at 760-456-5515 or frontoffice@3toe1footdoctor.com. Mobile opt-in information is never shared with third parties.