Sketch which part you are concerned about. Red is very troublesome, green is disturbing, blue is has pain but negligible.
Please sign within the box.
I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependents. I understand that payment is due at the time of consultation, unless other arrangements have been made with staff at the Lower Extremity Group.
I understand that there are additional costs for Strapping tapes, dressings, splints, orthotics, castings, footwear additions or other appliances provided to me as part of my treatment at the Lower Extremity Group.
The Lower Extremity Group requires 24 hours notice for cancellations or changes to appointment times. Lower Extremity Group prides itself on its results for our clients missed consultations are a sign of a lack of commitment to the process of rehabilitation.
Should you fail to attend an appointment without notice you will be required to pay the full consultation fee for the missed appointment before making further appointments. Appointments cancelled on the day of consultation may invoke a charge of 50% of the consultation fee.
Release of Information: I consent to the exchange of information, documents and test results between my Podiatrist and other parties involved to enable the complete management of my condition, including treating surgeon, GP, Therapists, insurance companies.