If you agree to the receipt of information electronically and wish to continue with the online application process, please indicate your acceptance by clicking the Continue button blow. Clicking the Continue button during this online application process, as well as clicking the Submit button, constitutes your agreement to the use of electronic disclosures and your electronic signature. Please Note: Once you agree to this and the following disclosure(s), you may cancel your application prior to submission at any time by closing your browser or linking to another page. Your application will not be received or accessible by us at any time unless you complete the entire application, click the Submit button and are brought to the Thank You page. Saving an application does not constitute receipt or submission of an application.

Submitting an application through this website constitutes your electronic signature. Any record containing an electronic signature shall be deemed for all purposes to have been "signed" and will constitute an "original" when printed from electronic records established and maintained by Your Total Foot Care Specialist, PA (YTFCS) or its agents in the normal course of business. Upon YTFCS's request, Patient agrees to manually sign or place Patient's signature on any paper original of any electronic record that YTFCS provides to Patient containing Patient's purported electronic signature.