Patient Registration Form - The Foot Health Professional

New Patient Registration Form (Annual updating)

Personal Details

Title

First Name

Surname

Preferred Name

Date of Birth

Occupation

Does your job involve prolonged standing at work?

Yes

Do you live on your own?

Yes

Are you able to reach your feet? (If you cannot but have someone who regularly helps you, please answer “Yes”.)

Yes

Contact Details

Home Telephone

Mobile Number

Address

Address Line 1

Address Line 2

City

Postcode

If you booked a home visit appointment, please help me to find your place more easily by sharing with me your Three-Words Location Finder Code of your address below.

To generate your what3words code, please click the link: https://what3words.com/

Do you know your What3words location code?

Parent's name (on child under 15 years of age) – Legal representative

Legal Guardian’s name

Family member / emergency contact name

Mobile Number

Patient’s GP and Surgery Information

GP Name

GP surgery name

Surgery

Address

City

Postcode

District nurse / diabetes nurse name (if known)

Mobile Number

Appointment Commitment

On making an appointment with me at Kovacs & Partners we are all agreeing to honour that commitment. The digital management software will send you a reminder about your booked appointment shortly after you booked in and 48 hours prior to the session.

At times things will get in the way and it will be necessary to reschedule appointments. I promise to give you as much notice as possible.

If you are unable to make your appointment, I would request that you let me know as soon as possible so that I can offer an appointment space to another patient.

In case of cancellation, please write me an SMS or WhatsApp message with your full name and date you would like to cancel as during the day I may not have the chance to answer phone calls or even listen to the left voice messages.

Cancellation policy

Please note that appointments can be cancelled free of charge up to 48 hours before the confirmed time. Cancellations made within 48 hours will be charged 50% of the service fee. Cancellations made within 24 hours, or in the event of a no-show, will be charged the full service fee. Thank you in advance for your understanding.

Use of patient information

To receive continuity and quality of care this information is recorded and may be shared with other members of the health care team involved in your care. We do not share your information with anyone who is not directly involved in your care.

Please read and sign to:

Confirm you understand our appointment confirmation.

Confirm the information you have provided is accurate and that you understand this information will be held securely to ensure safe and effective care.

Consent for treatment

Professionals are legally and ethically obliged to obtain informed consent prior to any treatment. At the first session, the professional will ask further questions and assess your condition. All necessary information and details will be discussed with you so that you can make an informed decision.

You will be given time to consider the treatment options and what is suitable for you - Your consent can be withdrawn at any time

A professional may use sharp instruments and other equipment that may cause minor damage to the skin surface

After your consultation our practice normally is to write to your GP for good communication.

I am happy for a letter to be sent to my GP

I do not want Kovacs & Partners to send a letter to my GP

We use clinical photographs of the feet to monitor changes over time and to support your treatment. Images are stored securely as part of your clinical record and handled in accordance with UK GDPR.

I consent to photographs of my feet being taken and stored in my clinical record.

I do not consent to photographs being taken.

I am happy to receive key patient information (Letters are not addverts or DM e-mails)

I do not want to receive key patient information (Letters are not addverts or DM e-mails)

How did you hear about us?

Please note that payment in cash or via bank transfer, on a self-pay basis, is required at the end of the consultation.

I confirm that I have read and understood the information above, that the details I have provided are accurate, and that I consent to my information being held securely and to treatment as described.

I accept the Terms and Conditions and Privacy Policy

If you are accompanying a person who may lack of capacity: Do you have legal authority to make health / welfare decisions for this patient?

Yes — Health & Welfare LPA (registered)

Yes — Court-appointed deputy (health/welfare)

If NO, than I understand my role is to help staff understand the patient’s values, wishes and preferences, not to provide my own opinion or make the decision.

Digital signature

Your Signature

Parent's - Legal representative's signature

Legal Guardian’s signature

NOTE: Your Computer IP Address, along with date and time will be recorded when you click 'Submit'