Making an appointment is easy; either email us at londonfootspecialist@yahoo.co.uk Or call 07960 045 745 to make an appointment.
Please print out and fill in this Health Questionnaire ready for your Podiatrist.
This questionnaire is for your safety and our information. The information is strictly confidential.
FULL NAME DATE OF BIRTH (DD/MM/YY) FULL ADDRESS
POSTCODE TELEPHONE Work: Home: Mobile: OCCUPATION COMPANY
NAME OF GP GP ADDRESS CONSULTANT HEALTH INSURANCE COMPANY (IF APPROPRIATE) POLICY NO GROUP NO/AUTHORISATION HOW DID YOU HEAR OF US?
MEDI Have you had any of the following? If yes, please tick
Heart conditions Cancer HRT Bladder problems Epilepsy Headaches Fractures Long Term steroids Pacemaker Car Accident Gynaecological Problems Circulation problems Osteoporosis Anti Coagulant Therapy Operations Dizziness Diabetes Rheumatoid Arthritis Hi Asthma What drugs are you presently taking?
As your comfort and safety is our priority please do not hesitate to tell us if you feel uncomfortable during the treatment or have any questions. I understand that I am responsible for the cost of my treatment. Should I fail to attend a treatment without giving 24 hours prior notice then I am liable for a cancellation fee. I consent to treatment by the Podiatrist in attendance.
Signature: Date:
Occasionally, I would like to email you information about their latest offers and new services.
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