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Consent Form

Consent Form

1. Patient Details
2. Medical History

Please tick any conditions you have now or have had in the past:

3. Allergies

Please list all known allergies (e.g. medication, dressings, latex, adhesives):

4. Current Medication

Please list all current medications (prescribed, over-the-counter, topical):

5. Presenting Problem / Reason for Visit

Please describe the foot or lower-limb problem you are attending for:

6. Additional Notes

Any other information relevant to your care (e.g. pain, mobility, footwear, work demands, recent injury):

7. Consent & Declaration

I confirm that the information provided above is accurate and complete to the best of my knowledge.

I understand that:

  • I will receive a podiatry assessment and, where clinically appropriate, treatment
  • Treatment may be provided in a workplace or clinic setting
  • Care will be delivered by HCPC-registered podiatrists
  • I may ask questions and withdraw consent or stop treatment at any time
  • My clinical records will be stored securely in line with UK GDPR

For workplace appointments only, I understand that:

  • Non-clinical summary information (e.g. attendance, fitness-for-work advice) may be shared with my employer or Occupational Health team
  • No detailed clinical information will be shared without my explicit consent
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