Name
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Phone
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Email
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Primary Insurance Company
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Referring Physician
Preferred Location
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Preferred Location * Blanding, Utah Cortez, Colorado Durango, Colorado – Podiatry Office Durango, Colorado – Primary Care Office Farmington, New Mexico – Podiatry Office Farmington, New Mexico – Primary Care Office Gallup, New Mexico – Podiatry Office Gallup, New Mexico – Primary Office Aztec, New Mexico Salt Lake City (Old Mill), Utah Idaho Falls, Idaho Layton, Utah Meridian, Idaho Monticello, Utah Pagosa Springs, Colorado St. George, Utah Gallup, NM - Primary Office Provo, Utah
Preferred Location
Health Condition
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Health Condition * Men's Health - Benign Prostatic Hyperplasia Men's Health - Varicocele Pain Management - Frozen Shoulder Pain Management - Osteoarthritis Pain Management - Spinal Fractures Podiatry - Achilles Tendon Injuries Podiatry - Ankle Injuries Podiatry - Bunion Treatment Podiatry - Corns & Calluses Podiatry - Diabetic Foot Care Podiatry - Flat Feet Podiatry - Foot & Ankle Surgery Podiatry - Foot Pain Podiatry - Gout Podiatry - Heel Pain Podiatry - Ingrown Toenails Podiatry - Laser Treatments Podiatry - Nerve Pain Podiatry - Neuropathy Podiatry - Orthotics Podiatry - Plantar Fasciitis Podiatry - Podiatric Surgery Podiatry - Sports Injuries Podiatry - Tendonitis Podiatry - Toe Nail Fungus Primary Care - Anxiety Primary Care - Birth Control Primary Care - Chronic Disease Management Primary Care - Depression Primary Care - Dermatology Primary Care - Diabetes Primary Care - Lab Testing Primary Care - Laser Treatment Primary Care - Pediatrics Primary Care - Physical Exams Primary Care - Preventative Healthcare Primary Care - Preventative Medicine Vascular - Peripheral Artery Disease Vascular - Vein Insufficiency Vascular - May-Thurner Syndrome Women's Health - Uterine Fibroids Women's Health - Pelvic Congestion Syndrome Wound Care Other
How soon would you like to be seen?
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How soon would you like to be seen? As soon as possible Within the next 7-10 days Within the next 30 days
Please share any additional information that can assist our team in scheduling your appointment.
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