Thank You For Choosing Cherrywood

Your first visit to The Cherrywood Foot Care Group involves a few special steps so that we can get to know you. To understand what to expect, please read through this page. New patients will find all the practical information they need, such as a map and directions to our office, practice hours, payment policies, and more. There’s also background information about our committed staff and our first visit procedures. You can also save time by filling out the form below before your appointment.

We Accept a Variety of Insurance Plans

We accept a variety of Insurance Plans. Conditions for qualification of new patients may depend on referrals or other factors. For details please call us at 516-826-9000 to discuss your coverage.

Book Your Appointment Today

Call to make an appointment at 516-826-9000 or schedule by clicking the button below:

New Patient Registration Form

Page 1 of 5

Step 1 of 5 — Personal Information

First Name*

Middle Initial*

Last Name*

Initials*

Date of Birth*

Age*

Sex*

Race*

Ethnicity*

Street Address & ZIP*

Phone (Home)*

Phone (Cell)*

Phone (Work)*

Marital Status*

Email Address*

Step 2 of 5 — Emergency Contact & Lifestyle

Primary Care Doctor*

Date Last Seen (PCP)*

Emergency Contact Name*

Emergency Contact Relation*

Emergency Contact Phone*

Alcohol Use*

Smoke?*

Packs Per Day*

Vape*

Step 3 of 5 — Insurance

Primary Subscriber DOB*

Primary Insurance / ID #*

Primary Subscriber Name*

Primary Relation to Insured*

Secondary Insurance / ID #*

Secondary Subscriber DOB*

Secondary Subscriber Name*

Secondary Relation to Insured*

Step 4 of 5 — Medical History

Patient Medical History*

Family Medical History*

List of Allergies*

Current Medications*

Flu Vaccine (past year)*

Pneumonia Vaccine (lifetime)*

Consent for RX History*

Pharmacy Name*

Pharmacy Address*

Pharmacy Phone*

Step 5 of 5 — Visit & Consent

Reason for Visit*

How Did You Find Us?*

If other, please specify

Referring Doctor*

SMS Consent

Yes

By providing my phone number, I consent to receive SMS text messages from Cherrywood Foot Care Group, P.C., including appointment reminders and follow-up messages. Message and data rates may apply. Reply STOP to opt out. View our SMS Terms (cherrywoodfootcare.com/sms-terms/) and Privacy Policy (cherrywoodfootcare.com/privacy-policy/).

I certify the above information is correct. I authorize Cherrywood Foot Care to allow me to electronically sign documents.*

Yes

Date of Signature*

This field should be left blank

By providing your phone number in the registration form above, you consent to receive SMS text messages from Cherrywood Foot Care Group, P.C., including appointment reminders and follow-up messages. Message and data rates may apply. Reply STOP to opt out. View our SMS Terms and Privacy Policy.

New Patients