SoleCare Podiatry
Foot and Ankle Care
Phone: (407) 360-9990

I voluntarily consent to podiatric evaluation, diagnostic testing, and treatment of my feet, ankles, and lower extremities by the doctors of podiatric medicine (DPMs), physician assistants, nurse practitioners, medical assistants, and other clinical staff of SoleCare Podiatry, and by those persons acting under their direction and supervision. I understand that this consent applies to my care at any SoleCare Podiatry office location and, where offered and arranged, to care provided in my home or at a residential or skilled nursing facility.

I understand that podiatric medicine is not an exact science and that no promise, warranty, or guarantee has been made to me regarding the result of any examination, treatment, or procedure. I understand that my treatment plan may change as my condition is evaluated over time.

This consent authorizes routine and customary podiatric services, which may include but are not limited to:

• Comprehensive foot and ankle examination, including vascular, neurologic, dermatologic, and biomechanical assessment.
• Trimming, debridement, and reduction of nails, corns, calluses, and hyperkeratotic tissue.
• Treatment of ingrown, thickened, or fungal nails, including chemical or surgical nail-border procedures (partial or total matrixectomy).
• Wound evaluation, sharp debridement, dressing changes, offloading, and ulcer care.
• Diagnostic imaging performed in the office, including X-ray and diagnostic ultrasound, and orders for outside imaging or laboratory testing.
• Local anesthetic injections and blocks; corticosteroid and other therapeutic injections; aspiration of fluid or cysts.
• Padding, strapping, taping, casting, splinting, immobilization, and application of walking boots or braces.
• Casting, scanning, or measurement for custom orthotics and dispensing of durable medical equipment (DME), including diabetic shoes and inserts.
• Minor in-office surgical procedures such as biopsy, excision of skin or soft-tissue lesions, incision and drainage, foreign-body removal, and treatment of warts.
• Prescription and administration of medications, including topical, oral, and injectable agents.

Any major or invasive surgical procedure not listed above will be discussed with me separately and will require a distinct procedure-specific informed consent before it is performed.

I have had the opportunity to ask questions about my condition, the recommended care, the expected benefits, reasonable alternatives (including the option of no treatment), and the risks of each. I understand that all medical and surgical care carries risk, and that risks associated with podiatric treatment may include, without limitation: pain, bleeding, bruising, swelling, infection, delayed or incomplete healing, scarring, allergic or adverse reaction to medications or anesthetic, nerve irritation or numbness, skin discoloration, recurrence of the original condition, regrowth or deformity of a treated nail, tendon or fat-pad atrophy or skin thinning from injections, blood clot, need for additional treatment or surgery, and, in rare cases, loss of function, limb, or life.

I understand that I may withdraw my consent or refuse any part of my care at any time, and that I am responsible for informing my provider if I do so.

If I have diabetes, peripheral neuropathy, peripheral arterial disease, or another condition that reduces sensation, circulation, or healing in my lower extremities, I understand that even routine foot care carries an increased risk of infection, ulceration, delayed healing, hospitalization, and, in serious cases, amputation. I agree to disclose these conditions and any change in them to my provider, to follow home-care and footwear instructions, to attend recommended follow-up visits, and to report promptly any redness, drainage, odor, swelling, fever, or new wound between visits.

I certify that the health history, medication list, allergies, and insurance information I have provided are true and complete to the best of my knowledge, and I agree to notify SoleCare Podiatry of any changes. I understand that inaccurate or withheld information may affect the safety and outcome of my care. I will inform my provider before any procedure if I take blood thinners or immunosuppressive medication, or if I am or may be pregnant.

I authorize SoleCare Podiatry to release to my insurance carriers, Medicare, Medicaid, and their agents any information required to process my claims, and I assign directly to SoleCare Podiatry all medical benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges regardless of insurance coverage, including deductibles, copayments, coinsurance, non-covered services, and any services my plan determines are not medically necessary. I understand that certain items, such as custom orthotics and some DME, may not be covered by my plan. I agree to pay any balance due, and I understand that unpaid balances may be referred for collection.

I acknowledge that I have been given the opportunity to review SoleCare Podiatry's Notice of Privacy Practices, which describes how my protected health information may be used and disclosed for treatment, payment, and health care operations. I authorize SoleCare Podiatry to contact me by telephone, voicemail, text message, email, or patient portal regarding appointments, test results, treatment, and billing, at the contact information I have provided, and to leave messages at those numbers.

I authorize SoleCare Podiatry to discuss my care and billing with the following individuals:

I consent to the taking of clinical photographs or images of my feet, ankles, and lower extremities for inclusion in my medical record, to document my condition and monitor healing, and for communication with consulting providers and insurers. These images will be handled as protected health information. Any use of my images for teaching, marketing, publication, or any purpose beyond my treatment record requires my separate written authorization.

Where a visit is conducted by telehealth, I understand that my provider will evaluate me using interactive audio and/or video technology rather than an in-person examination; that certain findings may not be detectable remotely and an in-person visit may still be required; that technical failure may interrupt or delay the visit; and that electronic transmission carries a small risk of interception despite reasonable safeguards. I may decline or discontinue a telehealth visit at any time without affecting my right to future in-person care.

I agree to provide at least 24 hours' notice when cancelling or rescheduling an appointment, and I understand a fee may be charged for missed appointments or late cancellations in accordance with practice policy. This consent remains in effect for the duration of my care at SoleCare Podiatry, including future visits and continuing treatment, unless and until I revoke it in writing. Revocation does not affect care already provided.

I have read, or have had read to me, this Consent to Treat. I have had the opportunity to ask questions, and my questions have been answered to my satisfaction. I understand its contents, and I am signing it freely and voluntarily. I certify that I am the patient, or that I am legally authorized to consent to care on the patient's behalf.