New Patient Consent Form
Patient Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number (excluding zero).
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
GP Practice
*
Occupation
*
Next of Kin / Emergency Contact
*
First Name
Last Name
Next of Kin Phone Number
*
Please enter a valid phone number (excluding zero).
Are you getting a carer?
*
Please Select
Yes
No
Care Provider details
Medications
*
List all medications you are currently taking (both prescription and non-prescription.
Medical History (Do you have or have you had any of the below treated in last 12 months)
*
Abnormal bleeding after surgery
Alcohol dependency
Allergies/Sensitivities
Blood clot
Blood disorders
Cancer
Currently pregnant
Delayed healing/sepsis
Diabetes
Do you or have you ever smoked?
Drug dependency
Endocrine/Hormone Condition
Epilepsy
Fractures/broken bones
Genetic Condition
Hearing Problems
Heart disease/angina/heart attack
Hepatitis/jaundice/kidney disease
High blood pressure
History of fainting
History of leg/foot ulcers
HIV/Hepatitis B/Hepatitis C
Joint Replacements
Memory problems
Mental Health Diagnosis
MRSA (Methicillin- Resistant Staphylococcus aureus)
Musculoskeletal problems
Neurological condition
Numbness in feet
Pacemaker
Peripheral Vascular Disease
Respiratory problems (e.g. asthma, COPD)
Rheumatoid or Osteoarthritis
Skin conditions (e.g. eczema, psoriasis)
Spectrum Condition
Varicose Veins
Vision Problems
Any falls in the last 6 months
Any other medical conditions
Attending any GP/Hospital clinics
Previous nail/foot surgery
Previous Podiatry Care
Other illness/operations
Other
Should any of these details change in the future then please let your Foot Health Practitioner know at the next appointment
Consent & Agreement
Please sign the below if you are happy to be treated by the Foot Health Practitioner(s):
I (the patient or parent/guardian), understand and consent to being treated by a Foot Health Practitioner(s) and I confirm that I am aware that Foot Health Practitioner may use medical instruments including nail nippers, scalpel, files and burrs and I understand my data will be confidentially retained for use by Medical Personnel only.
Name
*
First Name
Last Name
Signature
*
Date
*
-
Month
-
Day
Year
Date
Consent for Medical Foot Care Treatment
I, the undersigned, hereby give my consent to receive foot care treatment from **Litisha Foot Care **, a certified Foot Healthcare Practitioner. I understand that my treatment may include, but is not limited to:- Nail trimming and thinning- Corn and callus removal- Verruca treatment- Fungal infection management- Diabetic foot care- Involuted nail management- Advice on general foot health and footwear
Name
*
First Name
Last Name
Signature
*
Date
*
-
Month
-
Day
Year
Date
Potential Risks and Complications
I understand that while every effort is made to provide safe and effective treatment, there may be risks including, but not limited to:- Minor bleeding- Temporary discomfort- Allergic reactions- Infection (though rare)
Name
*
First Name
Last Name
Signature
*
Date
*
-
Month
-
Day
Year
Date
Consent for Medical Photography
If required, of my feet and lower limbs which will oberetained only on my patient file.
Name
*
First Name
Last Name
Signature
*
Date
*
-
Month
-
Day
Year
Date
Consent for Cancellation
I understand that booking a home visit appointment constitutes a commitment to attend. If I need to cancel or reschedule, I agree to provide at least 24 hours’ notice. Failure to do so may result in a charge for the missed appointment.
Name
First Name
Last Name
Signature
Date
-
Month
-
Day
Year
Date
Continue
Should be Empty: