Town Square Family Foot Care

Patient Registration Form

Please correct the errors described below.

From time to time we communicate with patients by Email and Text messages for appointment reminders and messages. You may opt out of these messages at any time.

➤ We will need to photocopy your insurance card(s)

    Please upload a file

    Current Medications:

    List all medications you are presently taking including all prescriptions, over-the counters, herbals and vitamin/mineral/dietary (nutritional) supplements with each medication’s name, dosage, frequency and administered route (oral, sublingual, subcutaneous injections, and/or topical):

    Add current medication

    List allergies to medications or tape:

    Add allergy

    List any past surgeries you’ve had and year of procedure:

    Add surgery

    List the medical conditions of your mother and father:

    Your information will be encrypted.