Title Mr. Mstr. Mrs. Miss Ms. Prefer not to say First Name Last Name Date of Birth Address Postcode Home Phone Mobile Phone Work Phone Main Contact Phone Email GP Address GP/Consultant PRIME CONTACT DETAILS/NEXT OF KIN First Name Last Name Phone Number Email Relationship HOW DO YOU WISH TO BE CONTACTED? PLEASE TICK HOW YOU WISH TO BE CONTACTED FOR: Treatment related purposes - e.g. appointments Telephone call Mobile text message Email Post Marketing Purposes Telephone call Mobile text message Email Post Height Weight Occupation Hobbies & Activities How you heard about the centre REASONS FOR SEEKING TREATMENT AT THE ACHILLES CENTRE Please give a brief description of your reasons for seeking treatment at the Achilles Centre? Have you received any previous care, treatment, or investigations for this complaint? Upload an image of your problem MEDICAL HISTORY If there has been a change in your medical history the treating practitioner will discuss this further with you during your appointment. Pick Statement That Best Applies New customer Returning customer - there has been changes in my medication and/or medical history in the past 12 months Returning customer - there has been NO changes in my medication or medical history in the past 12 months Prescribed Medication Non-Prescribed Medication Give brief details if you have had any illnesses in the past 12 months? Explain Your Medical History (Or Changes To It) CONSENT PLEASE TICK BELOW IF YOU ARE HAPPY TO BE TREATED BY THE PODIATRISTS AND/OR PODIATRY ASSISITANTS AT THE ACHILLES CENTRE 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. SHARING INFORMATION WITH REFERRING AGENT GP Insurance Company Private Medical Insurance Company CANCELLATION POLICY I will endeavour to give 24hours notice prior to my appointment if I am unable to attend. A fee may be charged for missed appointments. Signature Send
