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Form library · POD-001

Podiatry new patient intake

Example only. Not legal or clinical advice. Review and adapt before use. Not endorsed by any government agency. This example has not had a separate legal review.

Rules differ by state; check yours.

Podiatry clinics taking a first history for a foot or ankle concern.

The person says which foot, what the concern is, and answers a few foot-health questions. It is a questionnaire before an appointment. It does not diagnose or recommend treatment.

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Podiatry new patient intake

Example only. Not legal or clinical advice. Review and adapt before use. Not endorsed by any government agency. This example has not had a separate legal review.

Example only. Fictional clinic: Example Podiatry Clinic, Subiaco. This is a questionnaire before an appointment, not a diagnosis.

DD/MM/YYYY

Which foot or feet?

DD/MM/YYYY

Do you have diabetes?
Do you have numbness or tingling in your feet?
Do you have a sore on your foot that has not healed?

Privacy: Example Podiatry Clinic collects this information to provide your care. We may share it with the people who treat you. Read our privacy policy at example.com/privacy. Example only: the practice must write its own collection notice. See GEN-002.

Fields

  • Person

    Name, date of birth, mobile and email.

  • Which foot

    Left, right or both.

  • The concern

    In their own words, and when it started.

  • Foot health

    Yes or no: diabetes, numbness or tingling, and sores that have not healed.

  • Medicines and allergies

    In their own words.

  • Health information

    A tick. The practice collects the health information on the form for care.

  • Collection notice

    A line the practice writes before anyone uses the form.

  • Signature

    Signed on the phone.

Questions

Does a yes answer decide treatment?

No. It tells the podiatrist to read the answer. The form does not decide treatment.

Does this replace a consent form?

No. Pair it with the allied health consent to treat (AH-001).

About these templates

These templates are examples only, to help you get started. They are general information, not legal, medical, clinical or professional advice, and they may not suit your business, your profession or your state or territory.

Before you use any template, you must review and adapt it, and have it checked where needed, so it fits your services, your professional body's rules, privacy and health records laws, and the law where you operate. This matters most for consent, waiver, privacy and minors' forms. You are responsible for the forms you use and the information you collect.

To the extent the law allows, nopen gives no warranty that the templates are complete, current or fit for any purpose, and is not liable for loss arising from their use. Nothing here excludes, restricts or modifies any right or remedy you have under the Australian Consumer Law that cannot lawfully be excluded.

The templates are not endorsed by or connected with any government agency, including Services Australia, Medicare or the NDIA. Do not add government logos, the Commonwealth Coat of Arms or other official marks to them. Fields that refer to government numbers (such as a Medicare card number) are labels only.

Example only. Not legal or clinical advice. Review and adapt before use. Not endorsed by any government agency. This example has not had a separate legal review.