Board Certified Podiatrist | Your Total Foot Care Specialist
281.395.FEET (3338)
info@katyfootcare.com
Pay Bill
Menu
Podiatrist
How to Choose a Podiatrist
Dr. James M Jacobs
Dr. Mary Sandoval
Foot Conditions
Advanced Care
Patient Resources
Accepted Insurances
Blog
Scholarship Application
Scholarship Winners
General Office Policies
Tranquility Med Nail Spa
Podiatry Pillars
Locations
Contact Us
Schedule an Appointment
Click Here
Mon – Thur 8:30-5:00 PM
Fri – 8:30 – 3:00 PM
Schedule an appointment
@ Copperfield
Appointment Request Form
Which location would you like to request an appointment?
- Select -
Copperfield
Cypress
Katy
Memorial/Galleria
Preferred Date
Time of day
- Select -
Morning
Afternoon
First Name
Last Name
Are you a new patient?
- Select -
Yes
No
Address
Address Line 2
City
State
Zip Code
Email
Contact Number
Date of Birth
Gender
Male
Female
How did you hear about us?
- Select -
Family/Friend
Insurance
Google/ Social Media/ Online
Location
Physician
Others
If referred by a physician, please enter physician's name.
If referred by other channels, please specify.
Who is your primary care doctor?
What is the address of your preferred pharmacy to pick up your medication?
Insurance Carrier
Group (If none, put N/A)
Member ID
Claims Address (located on the back of your insurance card)
Reason for your visit
Height (feet and inches)
Weight (pounds)
Medical History: Allergies (Please select all that apply)
None Known Allergies
Adhesive Tape
Local Anesthetics
Aspirin
Penicillin
Iodine / Shellfish
Codeine
Demerol
Please list 'Other' allergies:
Medical History: (Please select all that apply)
AIDS/HIV
Allergies to Anesthetics
Allergies to medicine or drugs
Alzheimer’s
Arthritis
Artificial Heart Valve or Joint
Back Problems
Bleeding Disorders
Cancer
Chest Pain
Cholesterol
Circulatory Problems
Diabetes
Epilepsy
Gout
Heart Disease
Hemophilia
Hepatitis
High Blood Pressure
Liver Disease
Neuropathy
Phlebitis
Please list 'Other' Medical History:
If you are diabetic, what is your last hemoglobin A1C reading? (Enter N/A if not applicable)
Please list all major surgeries you've had in last 10 years. (If none, enter NONE.)
Have you had the flu shot this season?
- Select -
Yes
No
When was your last flu shot? If not applicable, enter NA
Pneumonia shot – If you are over 65, have you had a pneumonia shot?
- Select -
Yes
No
When was your last Pneumonia shot? (If not applicable, enter NA)
Are you currently smoking?
- Select -
Yes
No
What is your shoe size?
Submit Form
Home
Podiatrist
How to Choose a Podiatrist
Dr. James M Jacobs
Dr. Mary Sandoval
Foot Conditions
Advanced Care
Patient Resources
Accepted Insurances
Blog
Make a Payment
Scholarship Application
Scholarship Winners
General Office Policies
Tranquility Med Nail Spa
Podiatry Pillars
Locations
Contact Us
Podiatrist
How to Choose a Podiatrist
Dr. James M Jacobs
Dr. Mary Sandoval
Foot Conditions
Advanced Care
Patient Resources
Accepted Insurances
Blog
Scholarship Application
Scholarship Winners
General Office Policies
Tranquility Med Nail Spa
Podiatry Pillars
Locations
