"*" indicates required fields PhoneThis field is for validation purposes and should be left unchanged.Date of Birth* MM slash DD slash YYYY Name*PhoneSMS Consent By checking this box, I agree to receive conversational SMS from City Podiatry at the phone number provided above. The SMS frequency may vary. Data rates may apply. For assistance, reply HELP. Reply STOP to opt out of receiving text messages. Please review our Privacy Policy and Terms & Conditions.Email* Preferred Provider:Richard Goldstein, DPMJacqueline Sutera, DPMJoel Jezierski, DPMGlenn Weiss, DPMReturning/First Time: Returning First Time Insurance: Yes No If Yes, add Insurance provider:*Insurance Number:*Upload Insurance Card Photos or Documents Drop files here or Select files Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 10 MB, Max. files: 5. Message*Please use this form for general information purposes only. DO NOT send personal health information through this form. Specific patient care must be addressed during your appointment.Please complete the following form to request an appointment. Please also note that availability will vary depending on your request. Your appointment will be confirmed by phone by a member of our staff. Thank you! You can also book through Zocdoc
