Online New Patient Form

For your convenience you can fill out our online New Patient form below or you can download & print out the PDF version and enter your information before your visit.

Patient Information


Yes No

Emergency Contact
Relationship
Phone
Parent/Guardian Names (if child is under 18)

How did you hear about our click to our clinic?

Friend/Family/Colleague
Friend/Family/Colleague
Internet
Newspaper
Health Care Professional
Yellow pages
Outside sign


Help us help you!

Your foot problems involve:
Right Foot Only
Left Foot Only
Both Feet

Why are you here today?
Have you sought treatment elsewhere? Yes No

Have you ever been treated for or currently suffer with? (check all that apply)

Back pain
Warts
Heel pain
High arch feet/pain
Corns
Callouses
Bunions
Hammertoes
Gout
Broken foot/leg bones
Flat feet
Ankle injury
Neuroma
Knee pain
Ingrown nails
Childhood foot problems


What is your current:

In an average day, how much are you on your feet?
20%
40%
60%
80%
100%

What type of footwear do you wear most for work or leisure?
Safety shoe/boot
Athletic
Dress
Sandal
Other:

Do you currently use orthotics? (shoe inserts) Yes No

Check any sports or activities you participate in regularly:
Walking
Aerobics/Aqua
Fit
Hockey
Racquet Sports
Running
Golf
Soccer
Skiing
Other:


Please answer the following questions:

Do you have or have you ever been treated for? (Check all that apply)
Diabetes: Type 1 or Type 2
Heart Trouble
Hepatitis
Liver Disease
Urinary Problem
Depression
High Blood Pressure
Cholesterol
Cancer
Shortness of Breath
Stroke
Multiple Sclerosis
Heart Attack
Skin Disorder
Thyroid Problem
HIV/AIDS
Blood Disease
Anxiety
Bone Disease
Arthritis
Epilepsy
Tuberculosis
Stomach/Bowel Trouble
Varicose Veins
Circulation Problems

Other conditions we should be aware of:

Do you have any known allergies to?

Local anesthetics (e.g. Xylocaine, Novocaine) Yes No
Adhesive tape/band-aids Yes No
Latex Yes No
Other:
Are you slow to heal after cuts? Yes No
Do you bruise easily? Yes No
Are you currently pregnant or nursing? Yes No

Patient Physicians & Medical Specialists:


Please list your current medications (we can photocopy your list):



Please read:

I understand that I am financially responsible for all charges, whether covered by my health insurance plan or not. I authorize the Chiropodist to release all information necessary to secure the benefit of payments. I understand that fees for service are payable at the time of service and insurance reimbursement is my responsibility.
I hereby give consent for examination and treatment by the Chiropodist and/or anyone working in the clinic authorized by the Chiropodist and allow photographs of treatment areas for the purpose of monitoring.
I consent/allow the Chiropodist to send my Physician or health care professional a report regarding my foot exam and treatment plan.


You have two options for the form. You can submit the form directly to us and we will print it out for you to sign at your first visit or you can print it out and bring it with you.