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New Patient Form

Please complete this form prior to attending your appointment. Thank you!

Step 1 of 4

25%
  • Personal Details

  • Next of Kin or Parent/Guardian

  • For Your Visit

  • Please Note: Without written confirmation or approval of your claim for podiatry, we CANNOT bill to Work Cover or TAC. In this case, YOU are responsible to pay your account in full immediately after receiving treatment. You can then forward your receipt to TAC or Work Cover for reimbursement. We have set the full fee to be charged for a standard consultation up to 30 minutes for a TAC or VWA compensable client at our concession rate. This means that you will need to make an out-of-pocket payment immediately after the time of the provided service. We will then submit the compensable amount of the claim for treatment to the TAC or VWA in the normal manner.
  • Medical/Surgical History

  • Please specify below including year performed.
  • Please specify.
  • If unsure, please bring a list to next appointment.
  • Podiatric Medical History

  • Please Note: these images are ONLY used for completeness of your medical record and are NOT distributed or copied for any other reason.
  • Disclaimer (Please read carefully and sign below)

  • * All fees are due immediately at the end of your consultation unless otherwise specified. Some fees may be claimable from your Private Health Insurer.

    * A minimum of 24 hours notice is required for cancellations, otherwise a charge of 50% of the appointment fee will be incurred.

    * ProActive Podiatry does not accept any liability for any injury, loss or damage incurred by information omitted from this Client Information Sheet.

    * ProActive Podiatry rely on you giving us a full medical and surgical history to ensure you receive the best podiatric care. If you are unsure of any medications you are taking, please have your doctor fax us a copy of your complete medical history.

ProActive Podiatry
942 Nepean Hwy, Mornington VIC 3931
Call 03 5976 2377
Website by Malvolio
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