Please note that all fields with a (*) symbol are mandatory.
PATIENTS DETAILS
Please complete this form in full. If you have any queries regarding completing it, then please ask a member of staff for assistance. All information will be held in strictest confidence.
GDPR: in line with clinical policy we will normally keep your data for a minimum of 7 years.
PRIME CONTACT DETAILS/NEXT OF KIN
HOW DO YOU WISH TO BE CONTACTED? PLEASE TICK HOW YOU WISH TO BE CONTACTED FOR:
Telephone call
Mobile text message
Email
Post
(Leave blank if you do NOT wish to share your information)
REASONS FOR SEEKING TREATMENT AT THE ACHILLES CENTRE
Ensure file size does NOT exceed 4MB
MEDICAL HISTORY
If there has been a change in your medical history the treating practitioner will discuss this further with you during your appointment.
Please list all prescribed medication
Please list all non-prescribed medication
Diabetic
History of leg and / or foot ulceration
History neuropathy legs and / or feet
Endocrine disorders or conditions
Heart disease / angina / heart attack
Hypertension (high blood pressure)
Rheumatic fever
Circulatory problems
Hx blood clot / DVT or pulmonary embolism
Do you take a blood thinner
Respiratory problems
Do you smoke
Head or neurological problems
Bone and joint problems
Joint replacements / surgery
Implants, pins or plates
Foot surgery including nail surgery
Autoimmune disease
Rheumatoid arthritis
Hepatitis B / Hepatitis C / HIV
Liver disease / disorders
Renal or bladder disease / disorders
Cancer
Skin conditions
Memory loss
Visual impairment
Allergies / sensitivities
Could you be pregnant
I understand that I am to be assessed by a podiatrist.
I consent that my treatment today will be carried out by a podiatrist.
I confirm that I am aware that podiatrists/podiatry assistants may use sharp medical instruments, including nail nippers, scalpel, files and burrs.
I confirm that my data will be temporarily stored on the site for a period of 2 weeks from the time that I complete the online form (records will be kept at the Achilles Centre office for longer).
I confirm that I have answered the questions honestly and to the best of my knowledge.
GP
Insurance Company
Private Medical Insurance Company
I understand that if I have been referred for treatment via a third party, that my referring agent may be contacted regarding my care (Leave blank if you do NOT wish to share your information)
If you cannot see the submit button, it is because you have NOT yet agreed to all of the necessary terms.
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