Clinic Patient Registration Form

New Patient Registration

Please fill in the form below
Podiatry is a medical treatment and therefore we must ask for certain personal details. These are not shared with anybody else and are used for your medical record with us as per the General Data Protection Register. If you have any queries/require assistance regarding this form, please ask the at the reception desk or with the practice Manager.
Name*

First NameLast Name
E-mail*
Gender*
Title*

MrMasterMrsMissOther
Date of Birth*

DayMonthYear
Mobile Number:*

Area CodePhone Number
Address:*

Street Address

Street Address Line 2

CityState / Province

Post Code
In case of emergency...
Emergency Contact:

First NameLast Name
Relationship
Phone Number

Area CodePhone Number

Medical Information
All Conditions*
If none please type none.
All Alergies*
If none please type none.
Taking any medications, currently?*

YesNo
Prescription Form

Browse Files
Or list Cancelof
All Medications
Weight in KG*
Or best estimate.
Maximum Weight Limit for Podiatry Chair

Please confirm that your body weight, including clothing, does not exceed 24 stones (152 kg), the maximum weight capacity of our podiatry chair.
- Failure to declare your weight accurately may result in liability for any damage caused to the chair.
- We reserve the right to refuse treatment if there is reasonable suspicion of a false declaration or if your body weight exceeds the stated limit.
Do you smoke?*

YesOccasionallyNoOther

Communication and Appointment Policy

We may need to contact you to reschedule appointments due to unforeseen circumstances (e.g., podiatrist availability, adverse weather conditions).

Required Contact Information:

A mobile phone number for SMS notifications and access to the online diary.

An email address for additional communications.
If unavailable, a landline with an answering machine must be provided.

Policy for Missed Communications:

If you cannot be notified due to the absence of valid contact details, missed appointments will be marked as Not Attended (NA).

Patients with an NA record must pay for future appointments in advance.
Pricing and Cancellation Policy

Advance Booking Discount:

We offer a discount for patients who book appointments in advance.

Patients marked as Not Attended (NA) will lose the privilege to book in advance and must pay for future appointments upfront.

Rescheduling and Cancellation:

A minimum of 48 hours' notice is required for rescheduling or cancelling appointments.

Cancellations or rescheduling within 48 hours of the appointment will incur a charge equivalent to the full appointment fee.
Clinical Photography Consent

As part of your treatment, we may take photographs of your feet to document your condition and monitor progress.

Purpose and Use:

These images will be stored securely as part of your confidential medical records, in accordance with the UK General Data Protection Regulation (UK GDPR).

In exceptional circumstances, we may wish to use these images for training and educational purposes.

In exceptional circumstances, we may use these images for training and educational purposes.

Confidentiality:

All images are treated with the same level of confidentiality as your medical records.

They will not be used for any purpose without your explicit consent.

New Patient Registration

Medical Information