New Patient History Form

Welcome to the McRae Foot Health Centre. We are committed to providing exceptional foot care for people of all ages. Please help us get to know you by providing the following information.   

First Name:
Middle Name:
Last Name:
Date of Birth:
Address:
City:
Postal Code:
Telephone (Home):
Telephone (Work):
Cell Phone:
Occupation:
Email Address:
Emergency Contact Name:
Emergency Contact Telephone:
Family Physician:
Address:
Telephone Number:
Insurance Provider:
Policy Number:
How did you hear about our clinic?
Other:

Please answer the following foot questions:
Do your foot problems involve:
Why are you here today? Please explain your current problem(s):
Is this problem getting:
Have you had previous treatment for this problem?

Who did you see?
Other:
Have you ever had orthotics/shoe inserts?
Did they help your pain?
Have you ever been treated for: (Please check all that apply)
Have you ever had foot x-rays taken?
When/Where?
What is your current:
Weight:
Height:
Shoe Size:
Do you or have you ever been treated for: (Please check all that apply)
Diabetes Controlled by:
When were you diagnosed?
Other general medical conditions:
Are you pregnant or nursing?
Please list previous surgeries with dates:
Please list your current medications:
Do you have any known allergies to:
Local Anasthetics (eg. Xylocaine, novocaine)
Adhesive tape/band-aids:
Other drug allergies:
McRae Foot Health Centre will treat your personal information with respect. Our privacy protocols comply with privacy legislation, College of Chiropodists of Ontario standards and the law. Be assured that everyone in our office is committed to ensuring that you receive the best quality foot care.
Patient Consent
I hereby allow and consent to examination and treatment by the Chiropodist. I hereby allow myself to be photographed at the discretion of the Chiropodist. I consent the Chiropodist to contact my physician/healthcare provider to exchange information relating to my treatment. I understand that I am financially responsible for all charges whether covered by my health insurance plan or not. I understand that service fees are payable at the time of service.
Patients signature (or guardian):
Date:


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747 Hyde Park Rd. Suite 115
London, Ontario N6H 3S3
Phone: 519.474.7744
Fax: 519.474.7707

    Our Benefits

  • Restore natural function
    Using custom made orthotics, your feet
    will feel as great as they used to.
  • Release joint tension
    Orthotics helps to realign foot and ankle bones to neutral positions.
  • Get back to enjoying your life!
    Feel better and enjoy all your favorite
    daily activities.

New Patient History Form Book an Appointment