New Patient history Form

 
 

Welcome to the McRae Foot Health Centre. We are committed to providing exceptional foot care for people of all ages. Please help us get to know you by providing the following information.

McRae Foot Health Centre will treat your personal information with respect. Our privacy protocols comply with privacy legislation, College of Chriopodists of Ontario standards and the law. Be assured that everyone in our office is committed to ensuring that you receive the best quality foot care.

 

 

New Patient History Form

General Contact Information:
Full Name: *
Full Name:
Date of Birth: *
Date of Birth:
Address: *
Address:
Telephone (Home): *
Telephone (Home):
Telephone (Cellphone):
Telephone (Cellphone):
Telephone (Work):
Telephone (Work):
Emergency Contact Telephone:
Emergency Contact Telephone:
Family Physician Information
Family Physician Telephone: *
Family Physician Telephone:
Insurance Information
Please answer the following questions:
Is this problem getting:
Have you had previous treatment for this problem?
Have you used orthotics/shoe inserts?
Did they help your pain?
Medical history
Have you ever been treated for:
(Please check all that apply)
Have you ever had foot x-rays taken?
Do you or have you ever been treated for:
(Please check all that apply)
Do you have Diabetes?
Diabetes is controlled by:
(a specific date or year)
Are you pregnant or nursing?
Do you have any known allergies to:
Local Anasthetics. *
(eg. Xylocaine, Novocaine)
Adhesive tape/band-aids: *
(If no other allergies, please type 'none' or 'n/a')
Patient Consent
McRae Foot Health Centre will treat your personal information with respect. Our privacy protocols comply with privacy legislation, College of Chiropodists of Ontario standards and the law. Be assured that everyone in our office is committed to ensuring that you receive the best quality foot care.
I hereby allow and consent to examination and treatment by the Chiropodist. *
I hereby allow myself to be photographed at the discretion of the Chiropodist. *
I consent the Chiropodist to contact my physician/healthcare provider to exchange information relating to my treatment. *
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 of service. *
Patients signature (or guardian): *
Patients signature (or guardian):
Today's Date: *
Today's Date: