BEFORE YOU ARRIVE

 
Full Name(*)
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Email Address(*)
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Home Number(*)
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Cell Number
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Work Number
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Mailing Address(*)
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City(*)
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Province(*)
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Postal Code(*)
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Country(*)
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Birth Date(*)
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Shoe Size(*)
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Height(*)
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Weight(*)
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Family Doctor
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How did you hear about us?



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Reason For Visit(*)







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Specify Other
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What are your expectations for your visit?(*)
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Have you had a foot examination before?(*)
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If yes, with whom and when?
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Have you had a foot examination before?(*)

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Select any areas in which you have medical problems that have been diagnosed















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Specify Other
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Please list any surgeries, hospitalizations, or fractures(*)
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Please list any medications (prescribed or over the counter)(*)

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Please list
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Do you have allergies?(*)

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Please list
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OFFICE POLICY AND PRIVACY POLICY

OUR PLEDGE TO YOU: The Chiropodist and staff at this clinic will make every effort to give you the best quality care in a professional and timely fashion.

TIME IS PRECIOUS: We will do our best to see you at your scheduled appointment time. Therefore, we expect that all patients be on time for their scheduled appointments. If you are late you may have to be rescheduled for another date and time.

APPOINTMENTS ARE PRECIOUS: Our office staff sends email and text reminders, however, it is your responsibility to keep track of your appointments and arrive at our office for the scheduled date and time. Patient’s calling to cancel an appointment must give 24 hours notice or the full fee for the appointment is charged.

PRIVACY POLICY: Due to the privacy act, our office requires your permission to discuss your condition or treatment information with any of the parties listed below.

I consent to the staff of the North Bay Foot & Ankle Clinic releasing information about my treatment at the clinic to the following parties:
Reason For Visit

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Other/family members (please include name, phone number and indicate their relationship to you)
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Signed by patient or legal guardian(*)
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Date:(*)
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