REGISTRATION/UPDATE FORM

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Thank you for making an appointment at A&A Podiatrists. It is essential that we obtain some medical and general details before we are able to treat you. Some of the information we already have but is needed to match the form to your record. We are required to gain your consent to hold your data and explain our privacy policy to you.

To save everyone time this form is available to fill in now. There is the option at the bottom of the page to save your responses and return back to them later. We cannot treat you until this is complete.

We provide a link to this form on both your appointment confirmation and reminder so if you have already completed it recently then there is no need to do this again.

General Information

Email Address

Title *

Patient first name *

Patient surname *

Date of birth (DD/MM/YYYY) *

Mobile phone

Home phone

Work Information

Occupation

Health Information

What are you seeing us about?

Would you like to send us a picture of your problem?

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This may be useful if you are traveling a long distance to see us or are unsure of the nature of your problem. Please be aware that this document is automatically added to your file so please email us separately if you are waiting for a response.

Have you seen anyone about this?

YesNo

Treatment

Please list any medications you are currently taking

Do you take any medications (prescribed or self medicated)

YesNo

I will bring a list of medications with instead.

Please list your medications

Would you like to include a photo of your prescriptions?

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Do you have any allergies?

YesNo

Please provide information about your allergies:

Have you had any operations or procedure?

YesNo

Have you had any operations or procedures?

Do you smoke?

YesNoI used to smoke

Foot related questions

Foot Health Questions - tick any that apply

I have orthoses that I currently wearI used to wear orthosesI have difficulty in cutting my toenailsI suffer with athletes footI am seeking treatment for a fungal nail infection and specifically interested in using the lunula laserMy feet hurtI am seeking advice relating to foot pain as a result of sports/work

Tick any or none that apply. We may ask you some additional related questions or provide some helpful information in advance of your appointment about the conditions you tick

Here are some questions about your foot problem. This helps you to think in advance about it and helps us during the assessment.

Remember to bring shorts or suitable clothing if we are to assess your walking/lower limb.

A selection of your shoes is helpful since we will considering their role in your problem or assess if orthoses or insoles may be required.

If you have orthoses or insoles currently then bring them along.

Your weight

When did your problem start?

Do you know what caused your problem?

What treatment has been undertaken so far? Who else have you seen? Have you had any investigations or scans?

If you have anything more to tell us about your activities or lower limb problem please let us know here:

You have indicated that you have a fungal infection and the lunula laser treatment may be of interest. There are other options including tablets and topical treatments and some infections may not require treatment. This will all be discussed.

After this form, you will be sent to our website where you can read more about this if you have not already.

Here are some important points to take note regarding the lunula laser treatment for those patients who have made an appointment specifically with this in mind.

Please be aware that the lunula laser treatment requires weekly treatments over a period of an average of 6 weeks and we encourage treatment up to 12 weeks. The treatment takes 12 minutes per foot. We charge a fixed price for this average of 3 months treatment and will discuss the specific protocol when we assess your feet and nails as well as the effectiveness which is around 60%.

We specifically point this out to ensure that you are able to attend for treatment at this frequency during our opening hours: Monday to Thursday 8.30-17.30 and Friday until 14.30

Please indicate that you have read this: *

I understand the treatment frequency and times as statedI am not interested in lunula laser so this does not applyI need more information but I am now aware of the lunula method at this clinicI have read this and my needs are different and will discuss with the podiatrist at the appointment (or will call the clinic to discuss with the receptionist in advance)

Verruca Treatments: Important Information

What are verrucae? Verrucae are warts that appear on the feet. They're caused by the Human Papilloma Virus (HPV) and are usually harmless, but can sometimes be uncomfortable, especially if they're on a weight-bearing area.
How do you get them? The verruca virus thrives in warm, moist places like swimming pools and changing rooms. It can enter your skin through tiny cuts or breaks.
What you need to know: Verrucae often disappear on their own as your body fights the virus. However, there are many effective treatments available if your verruca is causing you discomfort.
The unpredictable part: How quickly a verruca responds to treatment varies from person to person. While some clear up quickly, others may take more time.
The good news: Your podiatrist will work with you to find the best treatment plan for your specific verruca.
Possible side effects: Some treatments can cause temporary soreness, and in rare cases, may leave a small scar. Your podiatrist will discuss this with you before starting any treatment.

Treatment Details

Home Remedies

Some people find success with over-the-counter treatments or natural remedies like tea tree oil. If you're diabetic or have low immunity, talk to your podiatrist before trying these.

Treatments Available at Our Clinic

Salicylic Acid: We use a higher concentration than over-the-counter options for better results. It's generally painless, but might cause some soreness for a few days.
Pyrogallol Ointment: This is another effective option, but it can temporarily stain your skin.
Cryotherapy (Freezing): This works best for smaller, surface-level verrucae. It might cause temporary soreness or blistering.
Verrutop: This liquid treatment helps dry out the verruca. It's painless and often effective.
Needling: This minor procedure can be a great option for stubborn verrucae. It involves stimulating your immune system to fight the virus. There's a small risk of infection, and you might feel some soreness afterwards.
Other Options: In some cases, your podiatrist might discuss additional treatments with you.

Cost: Treatment costs vary. Your podiatrist will give you a full breakdown before starting. Typically £60 initially then £40 for follow ups. Needling from £250. Cryotherapy additional £15. Other costs would be discussed.

The podiatrist will help you choose the right treatment and guide you through the entire process!

Consent I have read and understand the information above, including potential side effects. I agree to the discussed treatment plan.

Verruca Consent *

I have read the information and will see the Podiatrist to decide on the appropriate course of treatmentI need more information but I am now aware of types of verruca treatmentI have read this and my needs are different and will discuss with the podiatrist at the appointment (or will call the clinic to discuss with the receptionist in advance)I agree to having the verruca treated but haven't read this in full and know I can access this on the website (under verruca treatments) but I understand the general idea

Contact Information

You're almost done. Just some essential contact details and then the next page is the required privacy statement and consent to treatment.

Address *

Address Line 2

Town *

County *

Postcode *

Your GP Practice Name (and GP if you know) *

Your shoe size

How did you find out about us?Select Contact if you were referred by a medical professional and select Patient if you were referred by an existing patient

Who referred you to us?

Insurance/Payments

Most patients are self pay patients and settle their bill in advance or at the end of every treatment. Some patients have cash back plans for which we can provide an email receipt suitable for submission.

There are a few patients with insurance policies that cover the cost of treatment. If this is the case with you - you will need to ensure that you have authorisation in advance of the appointment. We reserve the right to take your card details on file or ask that you pay for treatment in advance.

If you wish to pay through insurance we can provide a copy of the paid invoice for you to claim back or you can provide us with your Policy details below. Please be aware, not all providers cover Podiatry treatments (and we are not registered with AXA and BUPA) and the majority do not cover orthotics or consultations regarding orthotics.

Please note is it the patient's responsibility to settle payments at the clinic & cover any shortfall from insurance claims.

Insurance Provider

Policy Number

Authorisation Code

Consent

If there is anything you do not consent to or have any particular requirements please let us know here.

We collect certain data from you to meet mandatory requirements regarding medical notes. There is a legal requirement to keep medical notes for a period of time after treatment. This can vary in length depending on your age and ability to consent but will be for a minimum of 7 years.
We take your privacy seriously and will take all reasonable steps to ensure the protection of your data.
We also collect data to assist in the administration of our business to provide you with an efficient service. We will use your contact details to notify you of your appointments / changes to scheduled appointments and/ or reminders about appointments.
We may use AI note taking. This can listen on the background or be used for dictation to imporve accuracy of notes and streamlining of processes. The company Heidi Healthcare (or others) are GDPR compliant, have 2 factor authentication for access control and no physical recording is made that could be played back.

Consent for treatment will be asked before any treatment is carried out and the aims and objectives together with cost explained. As with any treatment, outcomes can be variable. A treatment plan is created and agreed and outcomes monitored for optimum effect. We have been told to advise patients that podiatry often uses sharp implements and whilst rare, cuts to the skin could occur (which would be treated appropriately).
We do ask for a minimum of 12 hours notice of cancellation. This can be done by using the cancellation link in your appointment confirmation or by phone or email. A fee may be charged for missed appointments. Fees are due in full at the time of your appointment. A fee schedule is maintained on our website which you will be directed to after completing this form.

We take photographs of your feet to monitor progress over time which form your medical record. These may occasionally be used anonymously in health education or on social media. Please indicate if you do not agree to this use.

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