Name
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Phone
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Email
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Primary Insurance Company
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Referring Physician
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Preferred Location
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Preferred Location *
Cortez, CO Durango, CO - Primary Office Durango, CO - Podiatry Office Pagosa Springs, CO Idaho Falls, ID Meridian, ID Farmington, NM - Primary Office Farmington, NM - Podiatry Office Gallup, NM - Primary Office Gallup, NM - Podiatry Office Blanding, UT Holladay, UT Layton, UT Monticello, UT St. George, UT
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
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