Your Foot Doctor Patient Information Form
Please fully complete the form below to ensure our database is accurate.
All information collected is kept secure and confidential.
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Email *
Full Name *
Preferred Name *
Gender *
Required
Date of Birth *
MM
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DD
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YYYY
Residential Address *
Postal Address (if different from above)
Home Phone
Mobile Phone
Work Phone
Private Health Insurance
Clear selection
Have you been given and EPC Medicare Plan by your GP? *
If YES, Medicare Card Number
Medicare reference number
Clear selection
Medicare Expiry Date
MM
/
DD
/
YYYY
Do you have any concession cards?
Clear selection
Concession Card Number
Concession Card Expiry Date
MM
/
DD
/
YYYY
Are you with the NDIS?  (if yes we will email you a separate form) *
GP Name and Clinic *
Medical History
Please note medical conditions/surgeries/medications can impact on the treatment we provide you and it is essential that our Podiatrists are fully aware of your medical history.
Please tick if you have any of the following *
Required
Any Other Medical Conditions?
Please list all medications and supplements that you take on a regular basis
Please list any allergies
Occupation
Sports played/Hobbies
Your reason for visiting us today
Emergency contact, Phone Number and Relationship to you
How did you find us? *
If you selected a Family or Friend referred you, may we please have their name so we can send them a coffee voucher and also enter them in our monthly draw for a pair of shoes?
Do you consent to pay for all treatments and/or materials supplied at the time of treatment? *
Do you consent to Dry Needling if your Podiatrist suggests as an appropriate form or treatment? *
Do you consent to your Podiatrist discussing your condition/treatments with other Health Practitioners that could benefit your conditions? (E.g. Physiotherapist, Massage Therapist, Surgeon) *
Cancellation Policy
Please help us stay organised and on time by providing us with one working day notice (24hrs) if you need to reschedule or can't make your appointment. This allows us time to give that appointment to someone else. We may charge a fee if you don't turn up or you reschedule at short notice.
We understand that sometimes life gets in the way of scheduled appointment times, and we do take extenuating circumstances into consideration. We thank you for your understanding.
A fee may be charged for non-attendance or late notice appointment changes.   *
A copy of your responses will be emailed to the address you provided.
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