First name(s)
Last name
Date of Birth
Email address
Telephone (daytime)
Telephone (evening)
Telephone (mobile)
Shoe Size
GP Name
GP Address
Referred by
Health Insurer
Policy Number
Auth Number

Please refer to the attached information sheet regarding Health Insurance


I (Patient/Parent/Guardian) Understand that by signing this form:

  • I Agree with First Podiatry Ltd Fee Structure
  • All fees are to be paid on the day of my visit, including patients with medical insurance unless a pre-authorisation number is provided prior to the consultation. A receipt will be issued to allow me to re-claim this from my insurer. I arm responsible for all costs incurred. Payment is accepted by cash/cheque/debit/credit card
  • I agree to give 24hours notice for cancellation of appointment and understand that there may be an administration charge incurred.
  • I understand that a video may be used in consultation and agree to its use in clinical examination