North Hill Foot and Ankle Clinic

Client Intake Form

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Patient Information

Title

First Name *

Last Name *

Email Address *

Phone Number *

Home Address *

City *

State *

Zipcode/Postcode *

Country *

Date of Birth *

Sex *
Male
Female

Alberta Health Care # *

How Were You Referred to Our Office?
Internet
Referral
Yellow Pages
Community Ad
Other

Referring Physician

Specialty

Guardian Information (If Under 18)

Responsible Party (If Under 18)

Relationship

Occupation

Employer

Business Phone Number

Emergency Contact

Emergency Contact Name

Relationship

Emergency Contact Phone #

Emergency Contact Business #

Medical Information

Foot/Ankle Problem

Medications

Allergies

Consent for Treatment

TO THE BEST OF MY KNOWLEDGE, THE ABOVE INFORMATION IS CORRECT. I HEAREBY GIVE MY PERMISSION TO THE DOCTORS OF NORTH HILL FOOT & ANKLE CLINIC ASSOCIATES TO ADMINISTER TREATMENT AND PERFORM SUCH PROCEDURES AS DEEMED NECESSARY IN THE DIAGNOSIS AND/OR TREATMENT OF MY FOOT/ANKLE CONDITION AS AGREED UPON BY MYSELF. I UNDERSTAND THAT PODIATRY IS PARTIALLY COVERED BY ALBERTA HEALTH. I AGREE TO BE FINANCIALLY RESPONSIBLE FOR ALL CHARGES AS RELATED TO MY CARE.

BY SUBMITTING, YOU HERBY AGREE TO THE ABOVE.

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Client Intake Form

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