Registerationform - Foot Comfort Centre

Step 1 of 9

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Step 1 of 9 - Compliance Statement

We are required by law to provide you with information about our services and charges and to secure your informed consent before we see you or commence treatment.

This form is designed to allow us to share information about our practice and how we can help you.This form will also allow you to share important information about yourself and the reason why you would like to visit us.

Please read all the information carefully and try and provide as much information as you can. If there is anything you’re unsure about, don’t worry, just pick up the phone and call us and we’ll be happy to help. Thank you.

Data Protection Act 1988 Statement - For your reassurance the information you provide on this form will ONLY be used by Authorised Personnel for the purpose of Customer Registration.

Welcome & Data Protection(Required)

I have read and understand the above

Step 2 of 9 - Practice Information

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.

Confirmation(Required)

I confirm I have booked an In-Clinic appointment with Foot Comfort Centre

I confirm I have booked a Home-Visit appointment with Foot Comfort Centre

Step 3 of 9 - Appointment

Please confirm the date and time of your appointment

Date(Required)

Day

Month

Year

Time(Required)

00 to 23

00, 15, 30, 45

HOW DID YOU FIND US?(Required)

Step 4 of 9 - Therapist

Select your Therapist(Required)

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.

You may visit our website to review detailed biographies of each of our therapists.

Appointment with(Required)

I am happy to continue my appointment with

Step 5 of 9 - Patient

Who is completing the form(Required)

Patient

Parent

Guardian

Third Party

Parent Details

Guardian Details

Third Party Details

Who: Name(Required)

Who: Mobile No(Required)

Who: Email(Required)

Patient Details

Title(Required)

First Name(Required)

Last Name(Required)

Date of Birth(Required)

Day

Month

Year

Occupation(Required)

Address(Required)

Postcode(Required)

Email Address(Required)

Mobile No.(Required)

Home / Work No.

Shoe Size(Required)

Height (Cms)(Required)

Weight (Kg)(Required)

Activity levels

Low

Medium

High

Specify Activity

GP Practice

Step 6 of 9 - Charges

TREATMENT CHARGES

TREATMENT 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)

Step 7 of 9 - Payment Options

HOW WOULD YOU LIKE TO PAY?(Required)

Self Pay

Medical Insurance

Other

MEDICAL INSURANCE

Foot Comfort Centre and our therapists are not affiliated or 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 so from the perspective that your therapy costs will not be covered by your medical insurer.

Name of Third Party(Required)

Address(Required)

Mobile No(Required)

Email(Required)

MEDICAL INSURANCE OPTION(Required)

I have read and understand the information statement above and wish to continue treatment as a Self Pay patient. I am aware that if I choose to submit a claim, that my costs may not be covered.

Step 8 of 9 - Medical History

How can we help you?(Required)

MEDICAL HISTORY(Required)

I do not want to disclose my medical history

I do not have any relevant medical history or health problems

I would like to share the following medical history and current medications.

Details

Step 9 of 9 - Consent

CONSENT

Consent(Required)

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)

Name(Required)

Comments

This field is for validation purposes and should be left unchanged.

Welcome to Foot Comfort Centre

Parent Details

Guardian Details

Third Party Details

Patient Details

TREATMENT CHARGES

CONSENT