Eform: New Patient
Welcome! We're dedicated to providing exceptional footcare for people of all ages. Please help us get to know you better by providing the following information. Patients with serious medical emergencies should go to the nearest Hospital Emergency Department.
Once completed online, please click the “Submit” button on the form's bottom. Ensure you have been redirected to a confirmation screen before exiting. If you have not, there may be a required field that has not been filled out. We do not receive incomplete forms.
The initial visit fee is $80.00. Your first appointment is a combination of consultation and treatment. A complete examination and assessment of your feet, looking for lesions such as corns, calluses, warts, or range of motion/gait analysis examining foot function, circulation, sensation, color, and digital photos of both feet. Treatment options are then presented and discussed, your questions answered, and the next steps decided. Additional fees will be discussed prior to treatment.
Extended Health Insurance often covers routine foot care under Paramedical Services. OHIP does not cover Chiropody services. We will provide a receipt and necessary documents in the format of your preference, PDF or printed, at the end of each visit with all of the information your insurance company may require, which you may submit for reimbursement.
If you have any questions or concerns, please call our office at 705-444-9929 or email us at tony@abbottfootclinic.ca
Sincerely,
The Team at Abbott Foot and Ankle Clinic
Abbott Foot and Ankle Clinic
10126 Hwy#126, East, Unit#3, Collingwood, ON. L9Y1L5
705-444-9929 | tony@abbottfootclinic.ca | www.abbottfootclinic.ca
Please fill out with PATIENTS information ONLY
PERSONAL DETAILS
Your personal details. Please review them and make any necessary adjustments.
Title
Mr.
Mrs.
Ms.
Mstr.
Miss
Dr.
First Name
Last Name
Preferred Name
Gender
Female
Male
Non-Binary/Other
Unspecified/Prefer Not To Answer
Date of Birth
Address
Address 2
Province/State
City
Postal /Zip Code
Home #
Work #
Ext.
Mobile #
Other #
Preferred Phone
Home
Work
Mobile
Other
Email
Contact Method
Email
Phone
Mail
Sms
Employer/School
Occupation
Are you available for short notice appointments? (Check if available)
How did you hear about us (Internet, Walk-In, Referred)? If referred, please provide name of person/business.
Emergency Contact First Name
Emergency Contact Last Name
Emergency Relation
Emergency Phone #
We would also like to learn about your preferences for receiving information from us! Our clinic takes patient confidentiality seriously. We respect your privacy. Your information is safe and secure with us.
May we use your email address for
Financial documents
Appt related correspondence
Newsletter/Other
May we use your cell phone number for text message (SMS) appointment reminders?
Help us help you! Please answer the following foot questions:
Your foot problems involve:
Right Foot Only
Left Foot Only
Both Feet
Other:
Why are you here today, explain your current foot problem(s):
Is this problem getting:
Worse
Better
Same
Have you had medical treatment for this problem?
Yes
No
Are you currently being treated for:
Back pain
Knee Pain
Heel pain
High Arch feet/pain
Broken foot/leg bones
Ankle injury
Gout
Warts
Corns
Callouses
Bunions
Hammertoe
Flat feet
Neuroma
Ingrown nails
Childhood foot problems
Other:
to walk?
Yes
No
to stand?
Yes
No
to wear shoes?
Yes
No
to work?
Yes
No
If you have had x-rays, when were they taken?
(If possible, please bring a copy of your x-ray on CD to your appointment. Please inform the receptionist at your appointment so the x-rays can be uploaded to your medical chart)
Please provide current:
Height
Weight
Shoe size
On average, how much are you on your feet daily?
20%
40%
60%
80%
100%
What type of footwear do you wear most for work or leisure?
Safety shoe/boot
Athletic
Dress
Sandal
Loafer
Other
What type of footwear do you wear at home
Sock feet
Bare feet
Slippers
Athletic Shoes
Do you currently use orthotics (shoe inserts)?
Yes
No
Check any sports or activities you participate in regularly:
Walking
Aerobics/Aquafit
Hockey
Racquet Sports
Running
Golf
Soccer
Skiing
Other
Do you have or have you ever been treated for:
Heart Trouble
Hepatitis
Liver Disease
Urinary Problem
Stroke
Depression
High Blood Pressure
Cholesterol
Cancer
Shortness of Breath
Skin Disorder
Thyroid Problem
HIV/AIDS
Blood Disease
Stomach/Bowel Trouble
Anxiety
Bone Disease
Arthritis
Epliepsy
Tuberculosis
Diabetes
If you checked yes for Diabetes:
Type of Diabetes
Not Applicable
Other (high glucose fasting, etc)
Pre-diabetic
Type 2
Type 1
How long have you had Diabetes?
Have you ever had a diabetic foot ulcer or infection?
Yes
No
Have you ever attended a Diabetic Clinic?
Yes
No
Additional Information:
Are you slow to heal after cuts?
Yes
No
Do you bruise easily?
Yes
No
Are you currently pregnant or nursing?
Yes
No
Medications:
Please list your current prescription medications (or bring a printed record to your appointment and we will scan it into your medical chart)
Allergies:
Do you have any known allergies to:
Local anesthetics (e.g. Xylocaine, Novocaine)
Yes
No
Adhesive tape/band-aids
Yes
No
Other
Patient Physicians
Family Physician (if you do not have one, please enter "none")
Phone
Has your doctor treated your foot condition?
Yes
No
Other Medical Specialist
Type of Doctor
Phone
This is the most important part of this intake form.
In the last few months has there been change in your :
No Changes
Weight
Work
Activity
Footwear
Flooring at home or at work
Please explain:
Relating to your specific complaint(s), what would you like to accomplish during your visit today?
Patient Consent:
Please refer to our website for additional information and Patient Policies
I hereby consent/allow to examination and treatment by the Chiropodist and allow photographs of treatment areas to be taken for the purposes of monitoring.
I consent/allow the Chiropodist to contact my physician for any pertinent information required relating to my treatment or medical information.
I consent/allow the Chiropodist to send my physician or health care professional a report regarding my foot exam & treatment plan.
I understand that I am financially responsible for all charges whether covered by my health insurance plan or not and are payable at the time service is provided
I provide consent to be contacted via email regarding clinic updates and promotions.
Patient's Signature (or guardian):
We promise to treat your personal information with respect. Our privacy protocols comply with privacy legislation, the standards of the College of Chiropodists of Ontario and the law. Be assured that everyone in our office is committed to ensuring that you receive the best quality footcare.
We know your time is valuable…and ours is too! Out of respect for our staff and our other patients, we ask that you give us at least 24 hours’ notice if you need to cancel or change your appointment. This allows us time to offer that appointment to another patient who may be in pain.
There will be a $45.00 fee for all missed appointments and short cancellations.
