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Superior Steppers
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Home
About
Services
Contact Us
Request Appointment
Request An Appointment
Name
*
Contact Person's First Name (if booking for someone other than yourself)
*
Email Address
*
Confirm Email
Phone Number (do not use hyphens - only type the numbers)
*
Appointment Details
Do you have a prescription from a doctor? (required)
*
Yes
No
If yes, what is the name of the doctor who referred you?
Are you an existing patient at Superior Steppers?
*
Yes
No
Who is your insurance provider?
No Insurance Coverage
Greenshield
Blue Cross
Other
If other please state Insurance Provider
PREFERRED DAY(s) choose all that apply (required)
*
Monday
Tuesday
Wednesday
Thursday
Friday
PREFERRED TIME RANGE FOR APPOINTMENT (required)
*
Morning
Afternoon
Evening
As Soon As Possible
PRODUCTS / SERVICES REQUIRED (Check all that apply)
*
Bracing (Knee / Ankle)
Compression Socks
Custom Footwear
Custom OrthotiFoot Care ( Nail Care, Corns, Calluses , Warts, etc.)
Orthopedic Footwear
Other (describe in comments)
Comment or Message ( describe your foot problem or provide details on the products / services you require)
Consent
*
Confirm that you agree to our terms of service and cancellation policy by checking this box.
Submit appointment
