Consent Form

New Patients - Consent Form

Your Name

Your Email

Your Number

Your Date of Birth

Your Street

Your City

Your Postcode

Your Occupation

Emergency Contact Information

Emergency Contact Name

Emergency Contact Phone

Your Medical History

It is important that you answer these questions as honestly as possible to ensure you receive the best possible treatment. If you are not happy about any of the disclosure, please discuss this with your podiatrist, as these conditions or medications could have an effect when having an assessment or treatment.

Are you on any medication or have been in the last 6 months? If yes, please specify.

Yes

Medication Notes

Are you taking steroids or have been in the last 6 months?

Yes

Do you have any history of kidney or liver conditions? If yes, please specify

Yes

Kidney or liver condition notes

Have you ever had trouble with your heart? If yes, please specify

Yes

Heart Condition Notes

Have you ever had problems with your chest? If yes, please specify

Yes

Chest Condition Notes

Do you have any allergies? If yes, please specify

Yes

Allergies Notes

Do you suffer from high or low blood pressure?

High

Low

Have you ever had Diabetes? If yes, please specify

Yes

Diabetes Notes

Do you have a thyroid problem?

Yes

Do you have Arthritis? Rheumatoid or Osteoarthritis? If yes, please specify

Yes

Arthritis Notes

Have you ever injured or suffered from pain in the knees, hips or lower back? If yes, please specify

Yes

Knee Pain Notes

Do you have or have you had Epilepsy?

Yes

Do you have fainting attacks or blackouts?

Yes

Have you had surgery or recently been in hospital? If yes, please specify.

Yes

Surgery Notes

Have you had any infections such as MRSA, TB, HIV, Hep B or C?

Yes

Do you have any other medical conditions that we should be aware of? If yes, please specify.

Yes

Other Medical Conditions Notes

Is there a history of illness in your family? If yes, please specify.

Yes

History Of Illness Notes

Are you pregnant?

Yes

Do you use tobacco products?

Yes

Do you drink alcohol?

Yes

Do you have any eyesight or hearing difficulties? If yes, please specify.

Yes

Eyesight or hearing difficulties Notes

Your shoe size

Your weight

Your GP's Information

Your GP's name

Your GP's address

Consent to being treated by a Podiatrist

Consent given is in light of full information of risk of failure or complication as well as alternative therapies available.

I hereby give consent that I am to be seen or treated by a Podiatrist.

I hereby give consent that I am aware that Podiatrists may use medical instruments.

I hereby give consent that I understand the cancellation or no show policy.

I hereby give consent to anonymised photographs and/or videos for marketing purposes.

I hereby give consent to the use of the following: Clinical photographs/recordings for my personal health record only.

I hereby give consent to anonymised clinical photographs/recordings to share with other health professionals to seek advice and/or to provide education. This includes case studies.