Request an Appointment!

Use the convenience of our web site to request an appointment and save yourself a few extra "steps"!

Request an appointment online by completing the form below, or you may call us at our office at: 816-455-8900.

Our office will contact you upon receiving your completed form. (Note: if you have not received a call back within 24 hours from you request (Monday - Thursday), please follow up with the office at 816-455-8900 to make sure that the request was received.


Tell us about yourself:

* Required Information


Title / Salutation


First Name*


Last Name*


Date of Birth*


Insurance Company*


Daytime Phone Number*


Email Address*


Address*


City*


State*


Zip Code*

Please indicate how you would like to be contacted:

Phone

Email

Have you been seen by Fine Foot Care Center before?

Yes

No


Preferred Day of Week (Select top two preferred days):

Monday   Tuesday   Wednesday   Thursday   Friday  

*Please list the nature of your problem, question or comment: