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Podiatry New Patient Form

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Podiatry - New Patient Form

This form collects personal information and medical history and allows our team to focus on your health during your consultation with one of our practitioners. It typically takes less than 15 minutes to complete.

Smart Health treats all information submitted confidentially and securely in accordance with our Privacy Policy. If you do not wish to submit forms online please contact our Administration Team on 8293 1100 and we will arrange for you to allow time to complete prior to your appoinment in the clinic.

Patient Information
Emergency Contact
Regular GP/Referring Practitioner Details
Permission to contact your regular GP/Practitioner regarding your care and progress?
Do you see a Physiotherapist or Chiropractor?
Health Insurance, Medicare & Other Details
Private Health Insurance?
Do you have a Pension/Concession Card?
Pension Card Type
Do you have a Department of Veterans Affairs (DVA) Number?
Do you have National Disability Insurance Agency (NDIS) funding for your visit?
Will this consultation be a WorkCover OR Motor Accident claim?


Please note that if you are seeking treatment for a WorkCover/RTWSA or motor accident claim and your claim has not been approved you will need to pay for your consult on the day and seek reimbursement.

There may be an "out of pocket expense".

Medical History
Do you have a diagnosed heart condition or history of heart disease?
Do you have vascular disease (incl. chilblains, varicose veins, etc)?
Do you have diabetes or a family history of diabetes?
Do you have any infectious diseases such as Hepatitis or HIV?
Do you have any diagnosed kidney or liver disease?
Do you have asthma?
Do you have epilepsy?
Do you take any prescribed medication?
Do you have any allergies?
Consent & Privacy

Reminder & Marketing

Appointment Reminders
Marketing Preferences

Payment

Payment is required at time of service. We accept payment by cash or credit card.

A 24 hour cancellation notice is required if you're not able to attend the session time otherwise full payment is required for the session not attended. This will enable other clients to use the allotted time.

For non-attendance at an appointment full payment is required. 

If you are running late for your appointment, the appointment length will be shortened so that the next client is not inconvenienced.

Please note that if you are seeking treatment for a WorkCover/RTWSA or Motor Accident claim and your claim has not been approved you will need to pay for your consult on the day and seek reimbursement. There may be an out of pocket expense.

I acknowledge and accept responsibility for payment of all appointments and treatments

Privacy

Smart Health needs to collect information from you for the primary purpose of providing quality service, in order to thoroughly assess, diagnose and provide therapy. This information may be used for:

  • The administrative purpose of running the clinic.

  • Billing either directly through a Third Party such as an insurer or compensation agency.

  • Use within the clinic if discussing or passing your care to another practitioner within the clinic for your ongoing management.

  • Disclosure of information to your doctors or other health professionals to facilitate communication and best possible care for you.

  • In the case of an insurance or compensation claim it may be necessary to disclose and/or collect information that concerns your return to work to an insurer or your employer.

Smart Health treats all information collected confidentially and in accordance with the obligations required by the Privacy Act 1988 (Cth) (Privacy Act) to comply with the Australian Privacy Principles (APP) that regulate how private organisations collect, use, disclose, store, provide access to and destroy personal information. Details of Smart Health's Privacy Policy are available here.

To ensure the process of quality treatment provision, information about your assessment results and progress may be given to relevant other service providers, who are involved in your management. These may include your GP, specialists, allied health practitioners, or in the case of compensation claims - insurers, solicitors or employers.

I have read the above information and understand the reasons for the collection of my personal information and the ways in which the information may be used and disclosed and I agree to that use and disclosure. I understand that it is my choice as to what information I provide an that withholding or falsifying information might act against the best interests of my assessment and therapy progress.
I accept Smart Health's Privacy Policy

Treatment

I understand that as part of my initial consultation and ongoing care I may receive podiatric examination, diagnosis an treatment from the podiatrist and clinical team.

I acknowledge the following:

  • The nature, purpose and expected outcomes of any treatment will be explained to me before it is provided.

  • I will have the opportunity to ask questions and give or withhold consent for any specific procedure or treatment.

  • I understand that all care will follow professional standards and appropriate infection control protocols.

  • I agree to provide accurate medical history, including allergies, medications and existing conditions, to assist in safe care.

  • I understand that no guarantees can be made regarding treatment outcomes and that I an withdraw my consent at any time.

I consent to proceed with the initial consultation and any appropriate podiatric care as discussed with the practitioner.
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