What's your first name? *

 
Hey {{answer_hVVs}}, nice to meet you.
What's your last name? *

 
Whats your Date of Birth?

 
What is your gender? *


 
Now for your address...

 
What's your street name and number? *

 
Suburb? *

 
State? *


 
Postcode? *

 
Whats your occupation? *

i.e. are you on your feet all day?
 
Which private health fund are you with? *








 
What's your mobile number? *

We will call or send a text message to confirm your podiatry appointments
 
How would you prefer to receive appointment reminders?


 
Would you like us to email you important clinic information and special offers? *

     
 
How did you hear about Foot Faults Podiatry? *










 
What did you search for?


 
Please tell us the name of the physio/physio clinic that referred you

So we can say thank you!
 
Please tell us the name of the person who referred you

So we can say thank you
 
Which social media account?






 
Tell us a little bit about your feet...

 
Why have you decided to see a podiatrist?

 
Have you ever had any of the following problems...

 
Leg or foot ulcers?

     
 
Leg cramps at night?

     
 
Leg cramps when walking?

     
 
Have you ever broken any bones in your legs or feet?

     
 
Which bones have you broken?

if your not sure leave black
 
What is your shoe size?

Australian sizes = US sizes
 
What's your medicare number?

Including the reference number (beside your name)
 
Do you have a regular GP?

     
 
What is your GP's name?

 
Which medical center does your GP work at?

 
Did your GP give you a Medicare referral for podiatry?

Medicare Enhanced Primary Care (EPC) Referral. Eligibility is assessed by GP.
     
 
Are you eligible for Podiatry care under DVA?

Gold Card - D904 referral
     
 
What is your DVA card number?

 
Your nearly done {{answer_hVVs}} - we just need to ask a few important questions about your medical history

 
Do you have any medication allergies? *

     
 
Please list your medication allergies below

 
Have you ever smoked? *

     
 
Do you currently smoke? *

     
 
On average, how many cigarettes do you smoke a day? *


 
Do you drink alcohol?

     
 
What best describes your alcohol intake? *


 
Do you exercise?

     
 
How often do you exercise? *


 
Do you have any medical conditions? *

     
 
Do you take medication for any medical conditions?

     
 
Do you have (or take medication for) any of the following conditions...

 
Diabetes?

     
 
Poor Circulation?

     
 
Kidney Problems?

     
 
High Blood Pressure?

     
 
Heart problems?

     
 
Arthritis?

     
 
Please list any other medical conditions you have

Including any conditions you take medicaiton for
 
Do you take any blood thinners (e.g. Aspirin/Warfarin)?

     
 
TERMS & CONDITIONS OF TREATMENT *

Payment is required on the day of consultation. A deposit may be required to order some medical devices (e.g. custom orthotics). Should payment not be made I acknowledge that I will pay all additional fees and charges that may be incurred until the account is paid in full.

A parent or adult guardian must always accompany and sign for children under the age of 16.

HICAPS is not always available. Pension cards, DVA Gold cards, Private Health Fund and EPC details to be presented on each visit. The Podiatrist reserves the right to refuse treatment
Payment is required on the day of consultation. A deposit may be required to order some medical devices (e.g. custom orthotics). Should payment not be made I acknowledge that I will pay all additional fees and charges that may be incurred until the account is paid in full.

A parent or adult guardian must always accompany and sign for children under the age of 16.

HICAPS is not always available. Pension cards, DVA Gold cards, Private Health Fund and EPC details to be presented on each visit. The Podiatrist reserves the right to refuse treatment
     
 
LATE CANCELLATION/FAIL TO ATTEND POLICY

Supporting our podiatrists and other patients *

Please provide at least 24 hours notice when cancelling your appointment This enables us to fill your allocated time with another patient from our waiting list.

Cancellation can be made by phone call, voicemail, SMS, email, message via our website, or in person.

As per our late cancellation policy, if you do not provide 24 hours notice, fail to attend your consultation, or arrive late, the full consultation fee will be charged.


Please provide at least 24 hours notice when cancelling your appointment This enables us to fill your allocated time with another patient from our waiting list.

Cancellation can be made by phone call, voicemail, SMS, email, message via our website, or in person.

As per our late cancellation policy, if you do not provide 24 hours notice, fail to attend your consultation, or arrive late, the full consultation fee will be charged.


     
 
*YOUR PRIVACY IS IMPORTANT TO US

Please ask a member of the admin team if you would like a copy of our privacy policy which describes how Foot Faults Podiatry collects, uses, stores, shares, and protects your personal information.
*

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