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Date of birth
How did you find out about us? Who referred you?
Why are you here today? Please check all that apply:Nail CareBack PainHammer ToesNeuromaPlantar WartsKnee PainFlat FeetDiabetic Feet Calluses/CornsBunionsHeel PainPlantar FasciitisOther
Are you diabetic?NoYes, Type 1Yes, Type 2
Current Medications: (if you provide us with a list of medications, we can photocopy it for you)
Emergency Contact's Name:
Family Doctor's Name:
Family Doctor's address:
(Initial) I hereby allow and consent to an examination, treatment and photographs to be taken by the Chiropodist and/or anyone working in this clinic authorized by the Chiropodist.
(Initial) I hereby allow and consent the Chiropodist to send a report to my physician regarding my foot exam and treatment plan.
Attendance Policy: We have booked an appointment exclusively for you. We understand that sometimes events happen that require cancelling. Therefore, a minimum of 48-hour notice must be given for any cancellation or to reschedule an appointment or a fee may apply.
Please be on time for your appointment. If you are late, you may not be seen and may have to reschedule. If you arrive late and are seen, your appointment may be shorter and we may not be able to provide you with all the care you need. I have read and understand the above attendance policy.
Custom-Made Orthotics Payment Policy: A 50% deposit will be required if you are purchasing orthotics in order for us to order your orthotics. The case fee for custom-made orthotics is $495.00 ($395.00 for children under 14). This includes the casting, fitting, 4 months of follow-ups and one annual orthotic examination. There will be no additional charges to the patient for evaluation and adjustments to the orthotics during the 4-month follow-up period. The orthotics are warranted against defect and breakage by the lab for a period of 4 months.
Due to the nature of medical conditions, it is not possible to guarantee the effectiveness or results of prescription orthotic therapy. However, Bruyere Foot Specialists will make every effort to assure that these treatment modalities perform as best as possible. These orthotics are custom made for YOU and NOT returnable for refund or credit.
I understand that I am financially responsible for all charges whether covered by my health plan or not. I understand that service fees are payable at the time service is provided. I have read and understand the above Custom-Made Orthotics Payment Policy.