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. Our office 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)
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Home Phone:
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Email:
Requested Date and Time of Appointment:
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