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BioPed Footcare – Lasalle
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Clinic Name
*
Full Name
*
Phone
*
Email
*
Preferred Contact Time
Morning
Afternoon
Evening
Preferred Contact Method
Phone
Email
You may receive a Call/SMS/TEXT appointment confirmation.
Are You An Existing Patient?
No
Yes
From Another BioPed Clinic
Not Sure
Product/Service Information Request (Check All That Apply)
Custom Orthotics
Compression Socks
Bracing (Knee/Ankle)
Footwear
Skin Care (Corns/Calluses/Warts)
Medical Footcare
Other (Describe Below)
Other - Please Describe Below
How Did You Hear About Us (Check All That Apply)
Doctor or Other Healthcare Professional
Google or other Online Search
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Instagram
Word of Mouth (Family, Friend, Colleague)
Ad (Print or Radio)
Other
Consent
*
I authorize BioPed Footcare to Call or send a SMS/Text to communicate.
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