Foot Clinic of Hollywood

Caring and Experience You Can Trust

Dr. Michael Farkas, D.P.M.

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Request an Appointment and Insurance Information

Use the convenience of our online form to schedule an appointment and/or to provide us with your insurance information prior to your visit with us. Please contact our office once you complete this form or will contact you upon receiving your form.
Patient's First Name:
Patient's Last Name:
Subscriber Name:
Insurance Carrier and Phone Number:
Insurance ID #:
Subscriber's Date of Birth:
Patient's Date of Birth:
Relation of Patient to Subscriber:
Address Street 1:
Address Street 2:
City:
Zip Code: (5 digits)
State:
Home Phone:
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Email:
Requested Date and Time of Appointment:
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