Please read and fill in the self-referral form carefully.
All fields marked with a * must be completed, otherwise the system will not let you submit the form.
Fields marked with * are required and cannot be left blank.
If you prefer not to answer a required question, please type "N.A" in the box so the form can be submitted successfully
If you have already completed and submitted a registration form, some questions may be similar to those you have previously answered. You do not need to provide this information again; please enter “N/A” in the relevant box. However, consent sections must still be completed by ticking the appropriate boxes.
Personal Details
Contact Details
Description of your problem or concern
Medical History
Have you ever been told or diagnosed that you have any of the following:
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
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
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.
Digital signature:
Please note: this is a digital form. You do not need to print or hand-sign it.
To sign, please type your full name into the signature box and click Submit. This will act as your digital signature.
NOTE: Your Computer IP Address, along with date and time will be recorded when you click 'Submit'
Before clicking Submit, please check that all boxes have been completed. If a question does not apply or you do not wish to answer it, please write “N/A” in the box. Otherwise, the system may not accept the form.
