New Patient Form
Welcome
For us to provide high quality treatment it is necessary that we have the following information. We require you to provide us with your medical history before treatment can occur. Your privacy is paramount and will be protected. Our Privacy Policy is available on request.
|Name: | |Date of Birth: | |
|Preferred Name: | |Occupation: | |
|Address: | |
| |
|Home Phone: | |Mobile: | |
|Email: | |
|Emergency Contact: | |Relationship: | |
|Phone: | |Mobile: | |
| |
|GP Name: | |GP Contact: | |
| | | |
| | | |
|What issues bring you to the | |
|Podiatrist? | |
| | |
| | |
|How long has this been going on?| |
| | |
| | |
|What’s been done so far to help | |
|you? | |
| | |
| | |
|Are you experiencing any other | |
|issues with your feet or legs? | |
| | |
| |
|Medical History: | |
| | |
|Medication: | |
| | |
|Allergies: | |
|Social History (Sports/ Leisure, Smoking ,Alcohol): | |
| | |
|We are pleased to offer a complimentary appointment reminder service on the business day prior to your appointment. Please indicate your preferred |
|reminder method (): |
|SMS/ Text Message Phone Email No reminder |
| | |
|Patient Acknowledgement/ Consent: (please tick) | |
|I consent to podiatric treatment from JBM Podiatry | |
|I agree to give 24 hours’ notice if I am unable to attend a scheduled appointment | |
|I understand that images of my feet and/or legs may be taken as part of my treatment and I consent to these images being taken, stored| |
|and utilised as part of my care | |
|I consent to the particulars of my care being discussed with relevant health professionals involved in my care | |
|I agree to this consent remaining valid until such time as I withdraw my consent. | |
| | |Date: | DD / MM / YYYY |
|Signed | |
|Where did you hear about JBM Podiatry? (please tick) |
|Signage | |Search Engine | |Website | |
|Doctor | |Facebook | |Health Professional : | |
|Family/ Friend Name: | |Other | |
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