Podiatry New Patient Form

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PODIATRY – NEW PATIENT FORM
Patient Information
Name: Mr/ Mrs/ Ms/ Dr Last __________________________________ First ________________________ Initial_____
Address: _________________________________________________________________________________________
Suburb: ____________________________________________________________ Postcode: _____________________
Date of Birth: _______ / ______ / ______
Age: ________
Sex: Male/Female
Phone: (H) ________________________ (W) _________________________ (M) _______________________________
Email: ___________________________________________________________________________________________
Private Insurance: Yes/No: ________________________ Occupation:_________________________________________
In case of emergency, Notify: ______________________________________ Telephone: _________________________
Medical History
Allergies: ________________________________________________________________________________________
Medical History -please tick if you have any of the following:
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Asthma
AIDs/HIV
Rheumatoid
Hypertension
Stroke
□
□
□
Diabetes
Angina
Hearing Problems
Osteoarthritis
Gout
□
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Heart Disease
Eye Problems
Poor Circulation
Cancer History
Epilepsy
Other: ___________________________________________________________________________________________
Current Medication (prescriptions, over-the-counter and Vitamins):____________________________________________
___________________________________________________________________________________
What are your podiatric concerns?
How did you learn of our clinic?
 Friend/ Family:________________  Doctor:________________ Yellow Pages – Brisbane book /local guide/ online
 Web Search
 Website
 Springwood Sports Health
Fully Integrated Therapies
 Other:_________________________________________________________________________________________
I hereby consent and give permission to the PODIATRIST to administer and perform such procedures upon
me that the PODIATRIST deems necessary in the diagnosis and/or treatment of the extremity condition.
I understand that I am financially responsible for any balance due on my account.
_____________________
Signature of Patient, Parent, Guardian or Personal Representative
Date
Print name of Patient, Parent, Guardian or Personal Representative

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