1128 Kingston Road
Pickering, ON, L1V 1B4
Tel: (905) 420-9494
Fax:(905) 420-9449
Email: [email protected]
Website: www.pickeringwellness.ca

Chiropody Intake Form

Your name

Birth Date (dd-mm-yyyy)

Date

Height

Weight

Age

Occupation

Address

City

Postal Code

Home Phone

Work Phone

Mobile

Shoe Size:

Footwear (Types Worn):

Family Physician:

Guardians name(If under 18):

Guardians Phone:

Guardians name(If under 18):

Guardians Phone:

Who can we thank for referring you to us?

Other family members under our care:

Context of Care Overview:

Briefly explain your current foot issue and when it started:

Current Medical History:

Primary Insurance Company

Patients Full Name:

Insurance Company:

Insurance Policy Number:

File Number:

Name of Plan Member:

Policy Start Date:

Secondary Insurance Company

Patients Full Name:

Insurance Company:

Insurance Policy Number:

File Number:

Name of Plan Member:

Policy Start Date:

Our Privacy Policy at Pickering Wellness Center is in compliance with the privacy protocols and standards set by the College of College of Chiropodists of Ontario.

Print Name: _______________________________________________________________________________________________________________________________________________________

Signature X ______________________________________________________________________

Date: ______________________________________________________________________

Thank you for your consideration and cooperation.