HOW DID YOU FIND US?(Required)Passed byFriends & FamilyInternetDoctor or SpecialistMagazineOtherHow can we help you?(Required)Please select your therapist(Required)Anamaria Feher. Foot Health Practitioner & HygienistDaud Abdirahman. Chiropodist & PodiatristKristine Toce. Foot Health Practitioner & HygienistMartin Vine. Chiropodist & PodiatristMohammed Firoz Hussein. Foot & Ankle SpecialistSara Soccocio. Foot Care Nurse & HygienistSuhaib Molina. Chiropodist & PodiatristTHERAPISTS We are a group practice and our therapists include Foot & Ankle Specialists, Chiropodists, Podiatrists, Foot Health Practitioners, Foot Care Hygienists and Foot Care Nurses. We offer a full range or cosmetic, conservative and surgical services and our therapists also offer expertise in Pedorthics, Orthotics, Prosthetics, Beauty Therapy, Pedicure, Manicure and medical foot and ankle care. Some are our Therapists are registered with Professional & Regulatory Bodies whilst others are Independent Practitioners, all of whom have varying degrees of experience and expertise. You may visit our website to review detailed biographies of each of our therapists. If you are in any doubt as to the suitability of your Therapist, please speak with us and we will do our best to accommodate your needs or connect you with someone who can.Name(Required) Date of Birth(Required) DD slash MM slash YYYY Occupation(Required) Address(Required) Postcode(Required) Email Address(Required) Mobile No.(Required)Home / Work No.Shoe Size(Required) Height(Required) Weight(Required) Activity levelsLowMediumHighSpecify Activity(Required) GP Practice(Required) TREATMENT CHARGESTREATMENT CHARGES CONSENT 1(Required) I have been made aware of the cost of my consultation and or treatment.(Required)TREATMENT CHARGES CONSENT 2(Required) I have also been made aware that if additional charges apply, these will be discussed with me during my visit so that I can make an informed choice on the day.(Required)HOW WOULD YOU LIKE TO PAY?(Required) Self Pay Medical Insurance Other Name of Third Party(Required) Address(Required) Mobile No(Required)Email(Required) MEDICAL INSURANCE Foot Comfort Centre and our therapists are not registered with medical insurance companies. We will not assist you with any claims if you choose to reclaim the cost of your treatment from your medical insurer. You will be given a till receipt on the day of your visit to reflect the charges and services provided. We therefore recommend that if you wish to use our services, you do do from the perspective that your therapy costs will not be covered by your medical insurer.MEDICAL INSURANCE OPTION(Required) I understand the information above and wish to continue treatment as a Self Pay patient and will not submit any claims to my medical insurer. I would like to Self Pay and plan to reclaim the treatment costs from my medical insurer. I am aware my costs will not be covered and would like to continue treatment at my own risk. I would like to be seen by a Therapist who is recognised by and or registered with medical insurers. MEDICAL HISTORY I do not want to disclose my medical history I do not have any relevant medical history or health problems Heart Pacemaker Blood Lungs Stomach Kidney Liver Bladder Arthritis Rheumatic Fever Previous Surgery Hospitalisation Accident / Trauma Injuries Implants Spine or Back Problems Diabetes Neurological Problems Mental Health Gout High Blood Pressure High Cholesterol Depression HIV Hepatitis Sickle Cell Allergies Medication DetailsDATA PROTECTION ACT 1998 STATEMENT The information provided in this form will ONLY be used by Foot Comfort Centre for customer registration purposes, handled by authorised personnel in the course of their duties and stored securely.CONSENT I have read the Information given on this form, understand and accept the Fee Structure and confirm that the above Information provided by me is to the best of my knowledge accurate and I have not withheld any information that may be relevant to my treatment.Signature(Required)NameThis field is for validation purposes and should be left unchanged.