Online Medical Consent Form
Patient Information
Name
Age
Date of Birth
-
Month
-
Day
Year
Gender
Please Select
Male
Female
Email
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have Health Insurance?
Yes
No
Health Insurance Name
Insurance Policy ID
If you are Veteran please type Veteran number below:
POA or Emergency Contact Details
Contact Person Name
Primary Phone Number
-
Area Code
Phone Number
Medical Data
Do you have any known allergies? If yes, then please specify below.
Are you currently taking medications? If yes, then please list the medications and the reasons why are you taking them.
What is your current medical condition? Do you have any communicable disease, cardiovascular problems, diabetes, asthma etc.?
Acknowledgment, Authorization and Waiver
AGREEMENT:
I authorize EMILY SALTER to perform the treatment or necessary procedure to me/ or to my (for Parent/Guardian) dependent.
I confirm that the EMILY SALTER has explained the procedure thoroughly to me and how it will help me with my current condition.
I understand the risk to treatment, including but not limited to pain, swelling and infection. I do not expect EMILY SALTER to be able to anticipate and explain all risks and complications. I wish to rely on EMILY SALTER's nursing judgement to determine the care needed, to provide treatment and/or refer me to another health care professional for further assment and treatment as necessary.
I consent to photographs being taken by my foot care nurse. I understand that all my personal information is confidential and will be used for no other purpose than for my foot care nurse's clinical records and to comply with legal and regulatory requirements.
In the event of emergency medical aid/treatment is requried due to illness or injury during the process of receiving services, I give authorization to:
1. Secure and retain medical treatment/transportation if needed.
2. Confer with emergency personnel and disclose only relevant health history that may have an effect on my emergency care.
Failure to give 24h notice of a cancellation will result in a fee of 50% of appointment date.
I acknowledge that all information I provided int his form is true and accurate.
Method of Payment
Payments for visits is to be paid on the day of the service in full.
Cash/Cheque
E-transfer macverdure@outlook.com
Debit/Credit
Direct Billing through Insurance (forms to be completed at appointment)
Patient/Parent/Guardian Signature
Date Signed
-
Month
-
Day
Year
Submit
Should be Empty: