This information will assist me in your consultation; if you have any problems completing this, please let me know and I will help you complete it.
Name
DOB
Occupation
What is your complaint about your foot/feet?
Have you ever suffered from the following? (If yes please give details)
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Please give date of symptoms (if yes):
Please write below (Include inhalers, eyedrops, creams or herbal remedies whether prescribed by your doctor or not):
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Please list any previous operations or anaesthetics, year and any complications experienced,
i.e. scars, infections, delayed healing etc:
Year
Year
Year
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I also give my consent to being treated by the Podiatrist and I confirm I am aware that Podiatrists may use sharp medical instruments including nail nippers, scalpel, files and burrs in my treatment and following visits.
Centre4Feet 1 Ray Lane, Blindley Heath, Surrey, RH7 6LH. 01342 834454
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