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Precision footcare new patient form

PATIENT INFORMATION FORM
Would you like us to confirm your appointments by Email: Parent/Guardian Names (if child is under 18): How did you first hear about Precision Foot Care and Orthotic Centre / Vish Ramcharitar B.Sc., D.Ch., Ph.D.? (please indicate referrer's name so we may thank them) Help us help you! Please answer the following
What is your current:
foot questions:
On a n average day, how much are you on your feet? Why are you here today, explain your current foot problem(s): What type of footwear do you wear most for work or leisure? Is this problem getting: worse / better / same? (Circle one)
Have you had medical treatment for this problem? Do you currently use orthotics (shoe inserts)? Have you ever been treated for: (check all that apply) Check any sports or activities you participate in regularly: Continued on other side .
If you've had foot x-rays when were they taken? Please answer the following questions:
Do you have any known allergies to:
Do you have or have you ever been treated for:
Local anesthetics? (e.g. Xylocaine, Novocaine) Are you currently pregnant or nursing? Y N Patient P h y s i c i a n s & Medical Specialists:
Please list your current prescription medications: __________________________________________________ ______________________________________________________________ Has your doctor treated your foot condition? ______________________________________________________ Insurance / Benefit Plan Information:
Insurance Name: _________________________________________ _____________________________________________________________ Plan #: ______________________ ID #: ______________________ ______________________________________________________________ Plan Member Name: ______________________________________ ______________________________________________________________ Company’s Name: _______________________________________ D O B: (DD/MM/YY) ______________________________________ Patient's Consent:
I hereby allow and consent to examination and treatment by the Chiropodist and allow photographs of treatment areas to be taken for the purposes of monitoring. I consent/allow the Chiropodist to contact my physician for any pertinent information required relating to my treatment I consent/allow the Chiropodist to send my physician or health care professional a report regarding my foot exam and I understand that I am financially responsible for all charges whether covered by my health insurance plan or not. I understand that service fees are payable at the time service is provided. Precision Foot Care and Orthotic Centre promises to treat your personal information with respect. Our privacy protocols comply with privacy legislation, the standards of the College of Chiropodists of Ontario and the law. Be assured that everyone in our office is committed to ensuring that you receive the best quality footcare. Chiropodist's Signature: _________________________________________________ Date: _________________________

Source: http://www.precisionfootcare.ca/pdfs/pdfsNewPatientsForms/7_New_patient_form_31final.pdf

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