New Patient Registration Form

Welcome to Blacktown Podiatry

Please read the form carefully and complete where applicable

Phone

Family Doctor Information

Health Care Information

EMERGENCY CONTACT

YOUR CURRENT PROBLEM

According to the diagram below explain the Symptoms where you find it painful or where you are currently being treated for other pain as well. Often pains are related. If there is more than 1 area please explain briefly and then use the scale below to describe how painful.


Scale of Pain:

Zero Pain ......... 5 ......... 10 Worst

CONSENT AND ACKNOWLEDGEMENT

  • I give consent for treatment provided by podiatrists at Blacktown Podiatry
  • I agree to this consent remaining valid until such time as I withdraw my consent.
  • I give consent for my case to be discussed with relevant health professionals involved with my care.
  • I agree to the terms and conditions of the Appointment and Cancellation Policy of Blacktown Podiatry.
  • Consent to email newsletter.
  • Consent to take photographs of my feet for treatment purposes.
  • Consent to application of local anaesthetic when required.
  • I understand and agree that because of human variance and response it is not possible to warrant the outcome of any medical care or service.
  • I authorize Blacktown podiatry to have access to my E-Health record

If under 18 years of age

Thank you from the team at Blacktown Podiatry for taking the time to fill out this form completely. We look forward to helping you today and into the future.

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