Are YOU Ready for Comfy Feet? Appointment Request & Pre-Assessment Questionairre Let's get started on the road to comfy feet! Please fill out this form and we'll get an appointment set up for you. Only the contact information is required on this form. If you prefer, you may tell us the rest in person. Contact InformationPatient's Name* First Last Address* Street Address City State / Province / Region ZIP / Postal Code Phone 1*Phone 2Email* Patient HistoryDate of Birth MM DD YYYY HeightWeightDo you have a previous diagnosis of any foot-related health problem?YesNoPrevious DiagnosisPlease describe your previous diagnosis to the best of your ability.Primary Complaint?Please describe your primary complaint or concern when it comes to your feet. Where is the pain or discomfort? What brings it on? What, if anything, provides relief?Shoe Size?What size shoes have you been wearing the most in the previous 12 months?Referred by?Please tell us how you heard about Comfort Shoe Specialists.Appointment PreferenceHours of Operation: Tuesday-Saturday 10:00-6:00 Last appointment is 5:00Health Savings Accounts, Flexible Spending Accounts and InsuranceA current prescription is required to have on file if you plan on using these benifits.Which days are best? Tuesday Wednesday Thursday Friday Saturday Check all days that would work for your appointmentWhat time of day? Morning Mid-day Afternoon Check all times that would work for youAdditional notes:Any additional notes regarding your preferred appointment time?NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle AJAX powered Gravity Forms.