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Metropolitan Podiatry Associates, PLLC Appointment Request
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* Indicates required question
Name
*
First MI Last
Your answer
Date of Birth
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MM
/
DD
/
YYYY
Phone Number
*
xxx-xxx-xxxx
Your answer
Phone Type
*
Home
Work
Mobile
E-mail address
Your answer
Requested Date and Time
*
MM
/
DD
/
YYYY
Time
:
AM
PM
Which doctor would you like to see?
*
Either doctor
Dr. Kevin Jefferson
Dr. Berthie Labissiere
Is this your first visit with us?
*
Yes
No
What type of appointment would you prefer?
*
A telemedicine consultation requires a smart phone, tablet, or computer with a video camera and microphone.
In the office Located 7603 Georgia Ave NW Washington, DC 20012 STE 100
Telemedicine
What is the purpose of your appointment?
*
Examination and treatment
Bloodwork follow-up
X-rays/MRI/CT scan follow-up
Fungal nail culture follow-up
Medication/Prescription questions or refill
Postoperative follow-up
First visit evaluation
Pick up orthotics/shoes
Other:
Have you been exposed to the COVID-19 virus?
*
No
Yes, I tested positive
Yes, a member of my household tested positive
Yes, a close contact coworker/friend/other tested positive
I am not sure
If you tested positive for the COVID-19, what was the date?
Your answer
Have you been vaccinated against the COVID-19 virus?
*
No
Yes - first vaccine received
Yes - first and second vaccines received
Yes - first, second, and booster vaccines received
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