The Chestnut Tree Intake Form
PERSONAL DETAILS
Your personal details. Please review them and make any necessary adjustments.
Title
Mr.
Mrs.
Ms.
Mstr.
Miss
Dr.
First Name
Last Name
Preferred Name
Gender
Female
Male
Non-Binary/Other
Unspecified/Prefer Not To Answer
Date of Birth
Address
Address 2
Province/State
City
Postal /Zip Code
Home #
Work #
Ext.
Mobile #
Other #
Preferred Phone
Home
Work
Mobile
Other
Email
Contact Method
Email
Phone
Mail
Sms
Employer/School
Occupation
Are you available for short notice appointments? (Check if available)
How did you hear about us (Internet, Walk-In, Referred)? If referred, please provide name of person/business.
Emergency Contact First Name
Emergency Contact Last Name
Emergency Relation
Emergency Phone #
Information
Height:
Weight:
Shoe Size:
Medical Doctor:
Doctor Address (if known)
Doctor Phone (if known)
Insurance
Primary Insurance company:
Secondary Insurance company:
Subscriber name:
Subscriber name:
Subscriber date of birth:
Subscriber date of birth:
Policy #:
Policy #:
Subscriber ID #:
Subscriber ID#:
Relationship to Subscriber:
Relationship to Subscriber:
Medical History
Please check all conditions that apply
AIDS/HIV
Bleeding Disorder
Cerebral Palsy
Gout
High Blood Pressure
Osteoarthritis
Shortness of Breath
Artificial Joints
Cancer
Depression
Heart Attack
Kidney Problems
Parkinson's Disease
Stomach Ulcers
Asthma
Cholesterol
Diabetes
Heart Disease
Liver Problems
Polio
Stroke
Back Problems
Circulatory Problems
Epilepsy
Hepatitis A,B or C
Multiple Sclerosis
Rheumatoid Arthritis
Tuberculosis
Medical History
Are you diabetic?
Yes
No
If so, for how long, and how do you control it?
Have you had major surgery?
Yes
No
If so, please explain
Have you ever had a major leg or foot injury?
Yes
No
If so, please explain
Do you experience any numbness, tingling or burning sensations in your feet or toes?
Yes
No
If so have you been assesed for these feelings?
Please list any prescription or non-prescription medicine you are currently taking or have recently taken:
Do you have any allergies?
Have you ever experienced any side effects from local anaesthetics, penicillin or other medications?
Are you a smoker?
Yes
No
If so, amount per day smoked?
Non-smoker but smoked in the past? If so how long?
Foot Care
Please let us know about your foot concerns
What is the reason for your visit?
Have you seen a chiropodist before?
Yes
No
Have you ever worn orthotics?
Yes
No
If yes, are you currently wearing them?
Yes
No
Do you wear compression socks?
Yes
No
How did you hear about us?
Please let us know how your heard about our office!&edsp;
From a friend or family member
Referred from a doctor
Online (social media, website, search engines)
Other
Consent to Treatment and Fee Guide
Welcome to the Chestnut Tree Foot Clinic. Chiropody services are not covered by OHIP but may be covered by your third party insurance extended health care plan, DVA, ODSP, or WSIB. If you have any questions regarding the coverage of Chiropody services you should contact your health benefit plan provider. It is the responsibility of the patient to determine their insurance coverage. Chiropody services may be covered by ODSP, WSIB and DVA, however, pre-approval is required. If the request for approval is denied, the services fees are the responsibility of the patient.
Fee Guideline:
Initial Consultation: $80
If you haven't been to our office in the past 3 years there will be an initial consultation fee for the first visit back
Office VIsit: $55
Orthotics: $500
Orthopedic shoe: Prices vary based on shoe
Nail Surgery ( one side $400, two sides $450, per toe)
I acknowledge that the above information is correct. I understand that this information is confidential and will be used for no other purpose than for the patient's medical records
Yes
No
I hereby give permission for the exam, assessment and treatment of my foot conditions by the chiropodist
Yes
No
I understand that in the practice of chiropody, as in all health care, there may be sine slight risks to treatment. I wish to rely on the chiropodist to exercise judgement during the course exams and treatment that based on the facts known at the time, is in my best interest
Yes
No
I understand that it is my responibilty to pay for all services and products to the clinic and if I have private insurance it is my responsibility to submit it to my insurance company for reimbursment
Yes
No
