Appointment Request Form

To arrange an appointment with us, kindly fill in the details below. We'll reach out soon to confirm. Thank you! To Learn More Please Visit Our Website

Please Choose A Location*

Tinley Park - 6703 W 159th St Suite 110, Tinley Park, IL 60477Flossmoor - 19801 Governors Hwy #150, Flossmoor, IL 60422Downtown Chicago Office- 30 North Michigan Avenue, Chicago IL 60602

Please Select if you are a New Patient Visit or you are an Existing Patient at the Clinic*

New PatientExisting Patient

Briefly describe the reason for your visit

Requested Date of Appointment

Preference of Time

MorningAfternoonNo Preference

Patients Name*

First NameLast Name

Patients Date of Birth

MonthDayYear

Phone Number*

Please enter a valid phone number.

Email

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Upload Your ID (Optional for this form)

Upload Insurance Card (Optional for this form)

For assistance with this form please call/text us at 312-701-0770:

By submitting this form, I understand that this is a request for an appointment and not a confirmation of a scheduled appointment. The clinic will contact me to confirm my appointment date and time. I acknowledge that the information provided is accurate to the best of my knowledge. I also understand that my personal health information submitted through this form will be handled in accordance with HIPAA regulations to ensure privacy and confidentiality.

I give consent for Michigan Avenue Podiatry to send me email and text message notifications related to my appointment, as well as other relevant information regarding my care, through automated communication systems. I understand that I may opt out of these communications at any time by following the instructions provided in the messages.

In case of a medical emergency, I understand that I should not rely on this form for urgent care and should contact 911 or go to the nearest emergency room.