Chiropody (Foot Care) Intake Form

* = Required Field
Personal Information
Name*
First Last
Address*
Street Address City Province Postal Code
Home Phone*
Mobile Phone
Work Phone
Date of Birth*
Date Format: YYYY slash MM slash DD
E-mail Address
Occupation*
Length of time in position*
Emergency Contact
Emergency Contact Name*
Emergency Contact Relationship*
Emergency Contact Phone*
How did you hear about our clinic?
How did you hear about our clinic?*
Doctor's Name
Name
Social Media
- Facebook
- Instagram
- Twitter
Other
Doctor's Information
Family Physician's Name*
Doctor's Address*
Street Address City Province Postal Code
Family Physician Phone*
Family Physician Fax
Health Questionnaire
An accurate health history is important to ensure that it is safe for you to receive treatment and that assessment is directed accordingly. If your health status changes in the future please let your Chiropodist know.
1. What is the primary complaint that you are seeking Chiropody for?
- Difficulty cutting toenails
- Diabetic foot care
- Ingrown toenails
- Bunions
- Corns
- Athletes Foot
- Callus
- Flat feet or high arches
- Warts
- Knee pain
- Orthotics
- Low back pain
- Heel or arch pain
- Ankle pain
2. Do you presently have or ever had any of the following? Check all that apply:
- Arthritis
- Currently Pregnant (or think you may be)
- Stroke / TIAs
- Asthma
- High Cholesterol
- Lung Problems
- Cancer
- Liver Disease (fatty liver)
- Allergies
- Previous Surgeries
- Skin Disease of Sensitivity
- HIV/AIDS
- Epilepsy / Seizures
- Anxiety
- Digestive Problems
- Repeated Infections
- Depression
- Chronic Fatigue / Fibromyalgia
- High or Low Blood Pressure
- Osteoporosis / Osteopenia
- Sudden Weight Loss
- Pacemaker
- Parkinson’s Disease
- Fatigue
- Viral Hepatitis
- Metal Implants
- Diabetes
- Thyroid Issues
- Broken bones / fractures
- Other
3. Please give a list of all surgeries, past injuries or major dental work you have had:
4. Please provide a list of your current medications:
Consent
Please read the following carefully and fully:
Palermo Physiotherapy and Wellness Centre is a multidisciplinary health care provider where the practitioners work in conjunction to provide you, the patient, thorough care and treatment. All staff members are required to sign a confidentiality form with regards to your personal information and are trained in appropriate use and protection of your information.
All handling of your information is compliant with existing college guidelines and provincial and federal legislation. Our clinic uses your information to ensure you receive the best care.
I give Palermo Physiotherapy and Wellness Centre my consent to release / obtain information from the following individuals with respect to:*
- Physician(s)
- Insurer
- Family Member
- Employer
- Other
- None of the above / Not applicable
Physician(s)
Insurer
Family Member
Employer
Other
E-mail
- I give permission for Palermo Physiotherapy and Wellness Centre to use the email provided to send reminder emails of scheduled appointments, for paperless billing and for information regarding changes in clinics offerings.
Payment Information*
- 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.
Cancellation of Appointment*
- I understand that Palermo Physiotherapy & Wellness requires a minimum of 24 hours notice for any appointment cancellations. Should you give less than 24 hours notice, a $25.00 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)
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.
Rendering of Evaluations, Treatments and/or Services*
- 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/Guardian Name*
Date (yyyy/mm/dd)*
Date Format: YYYY slash MM slash DD
Signature*
Comments
This field is for validation purposes and should be left unchanged.