Patient Form
What to Bring to Your Appointment
- Patient's Health Insurance Card(s)
- Photo ID
- Primary Care Doctor's name and telephone number
- Referral From Your Primary Care Doctor (If Required By Your Insurance Carrier)
- List of current prescriptions and/or over-the-counter medication, including dose and frequency
- Information about patient's medical and surgical history
- Any Previous X-Rays, MRIs or Test Results Relating To Any Past Foot Health Conditions
Cancellations
If you are unable to keep an appointment, we ask that you kindly provide us with at least 24 hours notice. We ask for this advance notice so that we can offer this appointment to another patient. A fee may be charged if a patient does not show up for an appointment without sufficient notice.
Forms for Your Appointment
TO SAVE TIME, YOU CAN FILL OUT YOUR FORM BEFORE YOUR SCHEDULED VISIT.
Click here to download the convenient PDF fillable form to be completed for your visit. Fill out the form in its entirety. Please note: you will need Free Adobe Acrobat Reader or Preview on a Mac to view and type into this form.
TERRENCE s PARK Podiatry
Request Appointment Form
Contact our caring medical team to schedule an appointment or ask questions
When you send the message you understand and agree that any information submitted will be forwarded to our office by email and not via a secure messaging system. This form should not be used to transmit private health information, and we disclaim all warranties with respect to the privacy and confidentiality of any information submitted through this form.
