Chiropody Consent Form Patient (or Guardian) Name(Required) First Last What is the primary complaint that you are seeking Chiropody For?(Required) Ankle pain Diabetic foot care Corns Heel or arch pain Low back pain Athletes foot Difficulty cutting toenails Flat feet or high arches Ingrown toenails Orthotics Bunions Callus Fungal Knee pain Warts Payment InformationPayment Information(Required) I understand that payments for services at Palermo + Physiotherapy and Wellness Centre are my responsibility after every service is received. If my claim is to be submitted to an outside agency for payment, and for any reason the third-party payer, such as insurance or employer denies and/or refuses to pay for the full amount I am billed, I am responsible for payment.Chiropody Fees:Initial Assessment: $100.00 Follow-Up Session: $75.00 Cancellation of AppointmentCancellation of Appointment(Required) Palermo + Physiotherapy & Wellness requires a minimum of 24 hours notice for any appointment cancellations. Should you give less than 24 hours notice, a $45.00 cancellation charge may be charged. Your appointment time has been reserved specifically for you. Should you book an appointment and not to attend, you are responsible to pay for the entire cost of the appointment. Informed Consent for Assessment and Treatment (Chiropody)Informed Consent for Assessment and Treatment (Chiropody)(Required) During your initial visit, the Chiropodist will explain your diagnosis and discuss treatment recommendations that will result in the best quality of foot care. Throughout your visit(s), should you have any questions or concerns about any diagnostic procedures or recommended treatment, inform the Chiropodist immediately so rationale for treatments can be explained again and/or adjustments can be made.I hereby consent to the rendering of evaluations, treatments and / or services as communicated by the Chiropodist named below. I understand and am informed that, as in all health care, in the practice of Chiropody there are some very slight risks to treatment, including, but not limited to pain, swelling and infection. I do not expect the Chiropodist to be able to anticipate and explain all risks and complications and I wish to rely on the Chiropodist to exercise judgement during the course of the procedure which the Chiropodist feels at the time, based on the facts, is in my best interest. My consent is voluntary and I intend this consent to cover the entire course of assessment/treatment commencing on the date indicated below. I understand that I may ask questions at any time regarding the assessment and treatment and that this consent may be withdrawn at any time. Patient (or Guardian) Name(Required) First Last Patient (or Guardian) Signature(Required)Date(Required) Month Day Year NameThis field is for validation purposes and should be left unchanged.
