Patient Details Form

Please note that all fields with a (*) symbol are mandatory.

PATIENTS DETAILS

Please complete this form in full. If you have any queries regarding completing it, then please ask a member of staff for assistance. All information will be held in strictest confidence.

GDPR: in line with clinical policy we will normally keep your data for a minimum of 7 years.

Title:(*)

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First Name:(*)

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Last Name:(*)

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Date Of Birth:(*)

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Address:(*)

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Postcode:(*)

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Home Phone:

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Mobile Phone:

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Work Phone:

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Main Contact Phone:(*)

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Email Address:(*)

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GP Address:

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GP/Consultant:

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PRIME CONTACT DETAILS/NEXT OF KIN

First Name:

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Last Name:

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Phone Number:

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Email Address:

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Relationship:

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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

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Marketing Purposes:

Telephone call

Mobile text message

Email

Post

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(Leave blank if you do NOT wish to share your information)

Height:

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Weight:

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Occupation:

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Hobbies & Activities:

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How you heard about the centre:

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REASONS FOR SEEKING TREATMENT AT THE ACHILLES CENTRE

Please give a brief description of your reasons for seeking treatment at the Achilles Centre?(*)

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Have you received any previous care, treatment, or investigations for this complaint?

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Upload an image of your problem

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Ensure file size does NOT exceed 4MB

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(*)

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Prescribed Medication

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Please list all prescribed medication

Non-Prescribed Medication

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Please list all non-prescribed medication

Are you currently under investigation or receiving treatment from your GP / Hospital / consultant?(*)

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Give brief details of treatment(*)

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Give brief details if you have had any illnesses in the past 12 months?

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Explain Your Medical History (Or Changes To It):(*)

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Tick any that apply:

Do you have any other medical conditions?

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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.

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SHARING INFORMATION WITH REFERRING AGENT:

GP

Insurance Company

Private Medical Insurance Company

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I understand that if I have been referred for treatment via a third party, that my referring agent may be contacted regarding my care (Leave blank if you do NOT wish to share your information)

COVID CONSENT(*)

I confirm that I am aware that there is currently a COVID-19 pandemic and by being treated there is a small risk of transmission due to mixing with other people. The podiatrist will wear appropriate protective equipment and follow strict infection control protocols to minimise this risk as much as they can. I therefore consent to treatment with this knowledge. Invalid Input

Digital Signature:(*)

Sign Above

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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. Invalid Input

Complete the captcha task:(*)

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If you cannot see the submit button, it is because you have NOT yet agreed to all of the necessary terms.

Achilles Patient Details Form