Your medical history
It is important that you answer these questions as honestly as possible to ensure you receive the best possible treatment. If you are not happy about any of the disclosure, please discuss this with your podiatrist, as these conditions or medications could have an effect when having an assessment or treatment.
Are you on any medication or have been in the last 6 months? If yes, please specify.
Are you taking steroids or have been in the last 6 months?
Do you have any history of kidney or liver conditions? If yes, please specify
Have you ever had trouble with your heart? If yes, please specify
Have you ever had problems with your chest? If yes, please specify
Do you have any allergies? If yes, please specify
Do you suffer from high or low blood pressure?
Have you ever had Diabetes? If yes, please specify
Do you have a thyroid problem?
Do you have Arthritis? Rheumatoid or Osteoarthritis? If yes, please specify
Have you ever injured or suffered from pain in the knees, hips or lower back? If yes, please specify
Do you have or have you had Epilepsy?
Do you have fainting attacks or blackouts?
Have you had surgery or recently been in hospital? If yes, please specify.
Have you had any infections such as MRSA, TB, HIV, Hep B or C?
Do you have any other medical conditions that we should be aware of? If yes, please specify.
Is there a history of illness in your family? If yes, please specify.
Do you use Tobacco products?
Do you drink alcohol?
Do you have any eyesight or hearing difficulties? If yes, please specify.
Your GP's information
Consent to being treated by a Podiatrist
Consent given is in light of full information of risk of failure or complication as well as alternative therapies available.
Are there any changes to your health or medication?
I confirm that I understand the cancellation or no show policy
If you wish to cancel or reschedule an appointment, we simply ask you to give a minimum of 24 hours’ notice for up to 30 minute appointments and 48 hours’ notice for our longer appointments such as our biomechanical
assessments and nail surgery. If this minimum is not adhered to, we reserve the right to charge the full treatment
cost of the appointment. We appreciate there may be extenuating circumstances that prevent your attendance,
please let us know immediately.
I agree to the treatment above:
Consent for photography
I am happy for my photograph or video recording to be stored and used as indicated above
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