New Patient Intake form:
Michael L. Ashley C. Ped
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2 /Unit no.
City
State
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
About you
Date of Birth
*
/
Month
/
Day
Year
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Gender
*
Please Select
Male
Female
Rather not say
History
Have you been told you have any of the following :
*
YES
NO
Comments
Diabetes
Hypertension
CVA/ Stroke / TIA or mini-stroke
Thyroid Problems
Arthritis
Plantar fasciitis
Neuropathy
Foot Ulcers
Amputations
Charcot Foot
Date
*
-
Month
-
Day
Year
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How did you hear about us?
*
Please Select
Newspaper
Google
Facebook
Street sign
friends or family
Other (Please specify...)
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