CP - Screening Form for Podiatric Assessment

Podiatry - Patient Screening Form

For podiatric assessment as part of a clinical specialist appointment
Name*

PrefixFirst NameLast Name
Address

Street Address

Street Address Line 2

CityCounty

Post Code
* Please enter either a landline or mobile number below. This is required if we need to contact you about the information you provide on this form. Your private data will not be shared with any third party.
Your Mobile Number*
Mobile phone number
Your Landline Number (unnecessary if mobile number provided)

Area CodePhone Number
Email*
example@example.com
Date of Birth*

DayMonthYear
Please note:

This form is part of a screening process to help us select the correct type of appointment for you.
Is your problem related to:*

Skin and or nailsMusculoskeletal - muscle, bone, tendonBoth i.e., ingrown nail and heel pain
Diagnosis - Have you previously been given a diagnosis:*

Plantar fasciitisHeel painArch painMortons NeuromaPlantar plateAchilles tendinopathyBunionsAnkle sprainIngrown toenailVerrucaCornHard skinHypermobilityShin splintsCalf painRunning related injuriesOther
Insurance - Most Podiatry is self fund only. However, please let us know if you wish to activate your insurance with any of the following?

AllianzWPABupa - Jake Heath - Provider Number 85020312Bupa - David Gruhl - Provider Number 85013407
Please supply the Policy / Membership number
Please type the policy or membership number
Authorisation code
Please type the Authorisation code
Treatment authorised
Please provide details of the treatment authorised
Please provide results of any previous scans, x-ray or MRI (Please provide approx. dates).
Please provide approximate dates.
Could you be pregnant?*

YesNo
G.P.
Please type the name of your G.P.
Address of G.P. Surgery

Street Address

Street Address Line 2

CityCounty

Post Code
Please list any past medical history: (e.g., diabetes, high blood pressure, any surgery, prescribed medications and regular supplements)*
Have you had COVID-19 in last 10 days?*

YesNo
Please confirm that you consent for us to pass your email and telephone contact details to NHS track and trace service should we be required to do so (please note we will ever only pass on details if specifically asked to do so).*

I consent to provide my contact details for the NHS track and trace service.
Mobility
If you have any mobility issues please indicate which one from the list below. If your mobility issue is not listed, use the text box at the bottom to indicate your specific issue. If none, choose 'None'.*

Walking AidWheelchairUnable to climb a flight of stairsNone
Please note:

Angel clinic - has wheelchair access and disabled toilet facilities.

Chelsea clinic - does not have wheelchair access (lift is currently not working and could be a fairly long term issue) - access to the clinic by stairs (x1 flight of 7 steps).

Chelsea clinic - does not have disabled toilet facilities.

Lime St clinic - has wheelchair access and disabled toilet facilities.
Other mobility issue not listed above
Clinic location
Please choose which podiatry location is most convenient for your appointment:*

ANGEL ISLINGTON N1CHELSEA SW10LIME STREET EC3M
How did you find us?*
Pick one
Once we receive the completed form, this will then be screened by one of our senior clinicians. Once approved, one of our booking team will contact you to get you booked for an appointment – please note we aim to screen all consent forms within a maximum of 1-2 working days.
Signature*

I am the patient receiving treatmentI am signing on behalf of another person who will be receiving the treatment. I confirm that I am authorised to sign on their behalf and I have interpreted the information above to the patient to the best of my ability and in a way in which I believe s/he can understand.
To draw your signature: Place the mouse cursor in the area below, click and hold the left mouse button then move the mouse as if you were drawing.*
Should be Empty:

Podiatry - Patient Screening Form

Mobility

Clinic location