New Patient Registration Form

Title *

Name *

First

Last

Address *

Postcode *

Sex *

Gender identity

Date of Birth *

Mobile telephone number *

We send appointment reminders to mobile numbers

Landline telephone number

Email *

Email

Confirm Email

We will not share your email address with any other third party.

Occupation *

Your GP surgery address *

Include the name of your GP if applicable

Do you give us permission to contact your GP *

How did you find us? *

Next of Kin and contact telephone number *

List of medical conditions *

If no medical conditions please type NONE

List of prescribed medication *

If not taking any medication please type NONE

List any known allergies *

If you do not have or aren't aware whether you have any allergies please type NONE KNOWN

Are you pregnant *

Do you smoke? *

Select all relevant complaints *

When and how did this begin?

Applies to complaints concerning foot, ankle, knee or hip pain

Please describe if any activity makes your condition feel better or worse

If applicable, please select your pain level.

0 no pain, 10 maximum pain

Have you received any other treatment for your current complaint?

If YES, please describe above

Would you be happy for us to take images or videos of your feet, before and after the treatment? At times we would upload images and videos online to help raise public's awareness of various lower limb conditions. Anonymity will be kept at all times. *

You are providing consent to general podiatry on you or your child which can include, but not limited to, nail care, dead skin debridement (removal), corn treatment, verrucae reduction and assessment of podiatric need. Some treatments we offer will require further consent and will be discussed with your podiatrist if required. Podiatrists use sharp instruments to carry out treatments. Whilst every care is taken, there is a slight risk of injury whilst treatment. Treatments carry a very small chance of infection after treatments. Certain medical conditions may increase this risk. Patient data will be processed for purposes necessary to the treatment and according to our privacy policy. Please type in the field below 'I CONSENT TO THE ABOVE'. *

If the patient is under 16 years of age, this consent should be signed by a parent or legal guardian.

Name *

Date *

Please select who signed the form *

NEW PATIENT REGISTRATION FORM

Please provide as much information as possible. Thank you!