Patient Form

Are you filling out the form on behalf of the someone else? *

YesNo

Please specify your name and role/relationship with the client. *Note: When filling out this form, please continue to provide the client's information below. Thank you.

How did you find us? *Note: Contacts are Specialists, GP, or other health professionals

Please specify client's name. *

Please specify the NDIS Provider. *

Please specify the HCP Provider. *

If friend or colleague, please provide their name: *

If Gym or Sports Club, please specify the name. *

If Contact (Specialist, GP or other health professional), please provide their name: *

Please specify how did you find us and provide the name if available. *

Social Media *

FacebookInstagramLinkedIn

Signage *

NewmarketCBDOther

Please specify where the signage is located. *

Website *

Search engine (eg. Google, Yahoo, etc.)Internet advertisementHealth FundI went straight to thefeetpeople.com.au

Would you like keep up to date with our educational newsletters, important clinic updates and promotions? *

YesNo

What platform would you prefer us to send you the marketing promotions? *

SMSEmail

Do you have a preferred title? *

Title *

First Name *

Last Name *

Preferred Name *

Date of Birth *

Gender *

Gender (specify) *

Email Address *

Contact Number *

Street Address *

City *

State *

Postcode *

Occupation *

Emergency Contact Name and Number *Name, Contact Number, and Email Address

Relationship to client? *

POACarerRelativeOther

Please specify the relationship to the client. *

Do you have a regular General Practitioner (GP)? *

YesNone

Doctor's Name *

Medical Clinic *

Doctor Specialist *

Specialist *

Clinic AddressPlease provide the following if applicable: Stress Address, City, State, Post Code, Country

Please provide your Medicare details.

Medicare Number *

Medicare Reference Number *

Please note that our clinics are CASHLESS. We accept payment via EFTPOS, Visa, Mastercard or AMEX.

Fund Name

Fund Issue Date

Fund Member Number *

Fund Reference Number *

Note: Please remember to bring your card to your appointment.

Referring Doctor

Signed CDM Referral Form

Browse

Please include your name in the filename. E.g. JohnWilliams_MedicareReferral

To see a sample Medicare Referral Form, please click here. For any concerns, please contact our clinic.

DVA Card Number *

DVA Referring Doctor *

DVA Issue Date *

DVA Card Type *

Veteran Gold CardVeteran White CardVeteran Orange Card

Signed DVA Referral Form

Browse

Please include your name in the filename. E.g. JohnWilliams_DVAReferral

To see a sample DVA Referral Form, please click here. For any concerns, please contact our clinic.

NDIS Management Type *

Self ManagedPlan ManagedNDIA Managed

NDIS Number *

NDIS Provider *

Plan Start Date *

Plan End Date *

Funding Type? *

Capital supports - Assistive Technology: Prosthetics and OrthoticsCapacity building supports - Improved Daily Living Skills: Podiatry

Referrer Details

Referrer Name *

Referrer Contact Number *

Referrer Email Addresss *

Participant Support Person

Support Person Name *

Support Contact Number *

Support Email Address *

Plan Manager

Plan Manager Name *

Manager Contact Number *

Manager Email Address *

Does the Plan Manager wish to be advised of each appointment? *

YesNo

Support Coordinator

Support Coordinator Name *

Coordinator Contact Number *

Coordinator Email Address *

Does the Support Coordinator wish to be advised of each appointment? *

YesNo

Terms & Conditions

Checking this box will indicate that you have read and understood the Service Agreement Terms & Conditions and Privacy Policy. *

Who should we contact? *

ParticipantParticipant Support PersonReferrer

Organisation *Please include the Branch Code if applicable.

HCP Level *

Is there a generic email for your team, in case the referrer is away or leaves your organisation? *

YesNone

What email could it be? *

Do we have an existing brokerage agreement? *

YesNone

Case Manager Details *

Carer Details *

Invoice to: *

Email invoice to: *

Best person to contact for future treatment recommendations and reports?

Name *

Contact Email Address *

Claim Number *

Signed WorkCover Work Capacity Certificate

Browse

Please include your name in the filename. E.g. JohnWilliams_DVAReferral

To see a sample WorkCover Work Capacity Certificate, please click here. For any concerns, please contact our clinic.

Medical History

Check all that apply *

Pain (Arch, Forefoot, Heel, Leg, Knee, Hip, Back)Lower limb abnormalities (Bunions, Flat Feet, High-arched feet)Chronic Disease (Arthritis, Diabetes, Psoriasis)Mobility (Prevent Falls, Improve mobility)Skin and Nails (Cracked heels, Corns, Callous, Fungal, Ingrown, Warts, Wound)Vascular (Poor circulation, rest pain, swelling)

Please tell us where you are experiencing pain. *

Please specify what lower limb abnormalities you have. *

Please specify what chronic disease(s) you have. *

Please describe your level of mobility and concern(s). *

Please describe your skin or nail concern. *

Please describe what vascular concern(s) you have. *

Please attach your full updated medical history here if available.

Browse

Please include your name in the filename. E.g. JohnWilliams_MedicalHistory

Do you have any other medical conditions that is not specified above? *

YesNo

Please provide any medical conditions.e.g. Dementia, Alzheimer's Disease, Parkinson's Disease, etc.

Do you have any allergies? *

YesNo

Please specify your allergies. *

Are you on any current medications? *

YesNo

Please specify your medications. *

In a few words, what is the reason for seeking podiatry care and what is your desired outcome? *

Are any other health care professionals involved in your treatment? *

YesNo

Please specify the profession, clinic and doctor's name involved in your treatment that is not listed above. *

Please specify the doctor's name and clinic. *

Do you play any sports? *

YesNo

Please specify the sport(s). *

Do you do other exercise? *

RunningWalkingCyclingOther

Please specify the exercise(s). *

What shoes do you normally wear? *

Appointment Details

Contact Number for Appointment Confirmation *Note: All unconfirmed appointments will be rescheduled, please provide an active contact number so we can contact you prior to the appointment date.

Would you like to receive booking confirmation emails? *

YesNo

Would you like to receive booking cancellation emails? *

YesNo

What reminder type would you prefer us to contact you? *

SMSEmailSMS & Email

Client Location Request *

Clinic (Newmarket or CBD)Home Visit

Home Visit Risk Assessment

Should we expect anyone to be with you/the participant during the appointment or does anyone else live at the premises? *

YesNone

Who would that be? *

Do you have pets at home? *

YesNone

Note: If needed, please lock them away before the podiatrist arrives, e.g in another room or in your backyard, away from the main entrance.

Please specify the pet(s) you have at home. *

Do you have someone at home who is smoking? *

YesNone

Note: Please refrain from smoking before and during the appointment.

Is there adequate mobile phone coverage at your premises? *

YesNone

Do we need special directions to get to your property? *(Also advise if access to your front door is not clear, if you have stairs leading into your house or if road conditions are unsafe).

Where can we park? *

Are there any times you will regularly be unavailable for home visit services? *(i.e cleaners, other allied health appointments, respite)

Does the patient have any known history of unpredictable behaviour, violence, aggression or dementia? *

YesNo

The safety of our patients and podiatrist is of paramount importance. Are there any safety concerns regarding your medical conditions that we need to know about prior to visiting the client? *

YesNone

What would it be? *

Are there any additional risks we need to know about? *

YesNone

Please specify the risk(s). *

Risk assessment completed by: *

Goals and Consent

On a scale of 1 - 10 (1 = not committed, 10 = will do what it takes), how committed are you to achieving your desired outcomes and goals? *

Do you give consent for our podiatrist to contact other health professionals, such as your GP, involved in the treatment of your condition? *

YesNo

Do you agree to our podiatrist taking photos and videos of your lower limbs as part of your treatment information? *

YesNo

I consent to treatment by The Feet People *

Clear

Additional Attachments

Browse

Please don't forget to upload all necessary documents before clicking the 'Submit' button.

Save and Complete Later