Patient Intake Consent Form

(In accordance to Health Care Consent Act 1996 (HCCA))

Welcome to our Foot Care Clinic

As a patient at Appleby Foot Care & Orthotics, you will be seen by one of our registered, fully qualified Chiropodists.

Chiropody services are not covered by OHIP. There is an appointment fee for foot care services provided. Most extended healthcare benefits will cover Chiropody services; it is up to you, the patient, to submit to your insurer for reimbursement of the fees. Please contact your insurer regarding your individual coverage

Payment is required upon Chiropody services rendered.

For Orthotic Patients Only:

Payment of orthotic management deposits are required before manufacturing of the orthotic is initiated. The deposit is non-refundable. The orthotic management balance is due upon fitting of the orthotics. Every effort to satisfy the foot problem will be made, however, outcomes are not guaranteed.

It is the responsibility of the patient to check their insurance coverage. Custom Orthotics are non-refundable.

We politely request that you provide 24 hours notice for cancellation of an appointment. Charges may apply depending on the circumstances

I have read the above consent and by signing below, I consent to a Chiropody assessment appointment.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Name:

Witness/Guardian Signature:

Date:

Required if patient is under 18 years of age or if patient is incapable of consent (substitute decision-maker/guardian).

Your information will be encrypted.