Home Visit Questionnaire

Name of person completing this form:*

If you are not the patient, please give your name and relationship to the patient e.g. Mother, Father, Guardian, Carer

Please select one of the following statements:*

People aged 16 or over are required to consent to their own treatment. Like adults, young people (aged 16 or 17) are presumed to have sufficient capacity to decide on their own medical treatment, unless there's significant evidence to suggest otherwise.

I am 16 years old or older and I am completing this form for myself.
I am the parent or legal guardian of this patient who is under 16 years old.
I am an appointed the patients legally appointed Healthcare Power of Attorney (HCPA).ice
I am completing this form for the patient with their knowledge and consent.

Patient- Full Name:*

Please include preferred title.

Patient- Date of Birth*

Patient- Home Address*

Street Address Address Line 2 City ZIP / Postal Code Country

Is there parking available at the property?*

Please provide any special instructions the podiatrist will need to access the property?

e.g. code for a gate, door or key safe; call a telephone number, use a side entrance.

Please provide information about any pets in the residence:

Is the residence a smoking or non-smoking environment?*

Primary email address:*

Please add the email address to receive appointment confirmations.

Do you consent for clinical correspondence to be sent to you by your confirmed email?*

If this changes in the future and you do not wish to receive clinical correspondence such as letters, invoices or receipts via email, please email info@swpodiatry.co.uk

Primary mobile phone number:*

Please add the mobile phone number to receive appointment confirmations and important information about your care.

Do you wish to add an emergency contact?*

In the event the podiatrist has concerns over the patient's welfare and we cannot reach the primary contact telephone number, we may need to discuss the patient's medical care with the person named.

Please add your emergency contact name and phone number:*

Do you wish to provide details of someone who we can speak to on your behalf to discuss your medical record, pay for and arrange appointments ? *

This could be a partner, friend, parent, relative or carer

Additional contact name and telephone:*

May this contact schedule appointments?*

May we discuss your medical care with this contact?*

Consent to send letters*

We may need to send clinical letters to your GP or referring clinician to keep your medical record updated and possibly refer you to other services.

GP practice name and address*

Please provide your GP contact information. If you do not know the name of your GP, please put "The Doctor".

Name of Usual GP GP Practice Name

Please provide a brief description of the health condition(s) you would like South West Podiatry to assist with:*

Please list all patient's prescribed medication:*

You may enter "none" if appropriate.

Please list patient's existing medical conditions:*

Other than the condition for which the appointment has been booked. You may enter "none" if appropriate.

Please list any known allergies:*

You may enter "none" if appropriate.

Would you like to upload any documents to your file?

Please upload any any other information that may assist with this patient's care. This could include consultant letters, GP notes, or scan results. If you are an attorney under a patient's Power of Attorney (HCPA), please upload a copy of your documentation.

Drop files here or

Please select your consultation payment option:*

Self-funding
AVIVA
BUPA
CIGNA
Simply Health
Vitality
WPA
Other private insurance provider

If you are attending through private medical insurance, please check with your insurance company whether your Podiatrist is covered and pre authorised to provide Podiatry under your policy.

Name of private insurance provider:*

Please be advised we may not be able to bill your insurance provider directly. If so, you will need to self-pay and claim back from your policy.

Policy / Member Number:*

Providers may use either term for your policy number.

Authorisation code:*

Prior to attending your appointment, please ensure that you gain a pre-authorisation number from your insurance provider. If you have not done so, you will need to self fund your care.

Insurance policy excess*

How did you hear about South West Podiatry?*

CAPTCHA

By clicking the box and submitting this consent form you are digitally signing and agree to South West Podiatry's terms and conditions. T&C's can be found below. If you have any questions about the company's terms and conditions, please contact us via email: info@swpodiatry.co.uk. We may not be able to review you within our clinic if you fail to complete and submit this form.*

Please tick the box to continue:

Company Terms and Conditions (T&C’s):
1. Please note that we kindly ask for a minimum of 24 hours notice for re-scheduling or cancelling appointments within south west podiatry clinic.
2. I understand that failure to provide 24 hours notice will incur a charge of 100% of the appointment cost. This is subject to discretion and in line with the South West podiatry No Show policy. If you are attending under Private Medical Insurance, you may be personally liable for failed to attend consultations.
3. I understand that personal information is confidential and will be used for no other purpose than my medical record and to comply with legal and regulatory requirements of Royal College of Podiatry, Health Care Professions Council and ICO.
4. South West Podiatry are members of the ICO with processes in line with EU and GDPR regulations. As a medical facility your medical and personal data is securely stored for a minimum of 7 years and no paper records are held. If you require a copy of your medical record please email info@swpodiatry.co.uk and the company has 30 days in order to provide your subject access request (SAR).
5. South West Podiatry work with external providers including the NHS. If you are referred into our service via private medical insurance companies or NHS providers, the company has contractual obligations to hold your personal data. If you wish to discuss your data held by South West Podiatry please email the Data Controller directly: liam.mcmanus@swpodiatry.co.uk
6. I hereby request and consent to podiatry treatment and consultation. I give the podiatrist permission to perform, necessary examinations and assessments, as well as diagnostic procedures and treatments as may be deemed necessary, in order to provide me with the best quality service.
7. I understand that all services provided by the clinic are non-refundable. If you have any concerns about your treatment, please email info@swpodiatry.co.uk and we will take reasonable steps to resolve your concerns.
8. I consent to photographs, videos and audio to be taken by the podiatrist and/or anyone working in this clinic authorised by South West Podiatry. Photographs are occasionally uploaded to our secure practice management software system and stored for future reference. Social media photographs: The Podiatrist will always ask verbal consent to use your photo on our social media platforms.
9. I allow and consent to the Podiatrist to send a report to associated allied health professionals and my GP, when required, regarding my examination and treatment plan. Please inform your clinician if you do not wish South West Podiatry to send consultation letter correspondence to your GP or mutual allied health professional.
10. I understand and am informed that, as in all health care, in the practice of podiatric medicine, there are some risks to treatment. I do not expect the Podiatrist to be able to anticipate and explain all risks and complications and I wish to rely on the podiatrist and consent for the clinician to exercise judgement during treatment.
11. Our clinicians use a shared decision-making approach to your care, gaining verbal informed consent for treatment. We may also request formal consent for advanced procedures.
12. An adult is a person who is 16 years and over. South West Podiatry require all adults with full capacity to schedule consultations. If you prefer someone else to make bookings on your behalf, please advise South West Podiatry via email or telephone who you wish to authorise, such as a parent or partner.
13. Mental capacity and consent for adults: If you are scheduling an appointment for an adult over the age of 16, South West Podiatry require consent from the individual to hold their personal data and schedule a consultation. If you have financial and health related power of attorney, we will request a copy to be sent via email to info@swpodiatry.co.uk.
14. Mental capacity and consent for children under the age of 16: If you are scheduling an appointment for a child under the age of 16, South West Podiatry require a parent or legal guardian to schedule, attend and make decisions regarding the consultation.
15. You should receive an SMS and Email confirmation at the time of booking and 24 hours prior to your appointment. If you have not received confirmation of your appointment, you may not be booked. Call 02071646607 or email info@swpodiatry.co.uk to confirm if you are unsure.
16. If you would like any further information or would like to cancel your consultation outside of the 24-hour notice period, please contact us on info@swpodiatry.co.uk or 020 7164 6607
17. South West Podiatry’s terms and conditions for reviewing BUPA recognised patients within our service: In all cases through BUPA, South West Podiatry will bill your insurance company for each consultation on behalf of the Podiatrist. It is your responsibility to inform BUPA and gain pre-authorisation prior to each consultation. If you fail to gain pre-authorisation, you will be liable for any costs occurred. South West Podiatry charge a £30 self-pay fee to each patient following each consultation to cover administrative costs including dressings or medications used within the consultation. BUPA do not have contractual obligations with the company, South West Podiatry and the company charge a self-pay fee of £30 to cover the shortfall in costs to provide a Podiatry service. The charge is not set by individual Podiatrists and is external to contractual arrangements between BUPA and the Podiatrist. BUPA have agreed fee assured consultation fees with individual Podiatrists and not the company, South West Podiatry. In order to be reviewed within South West Podiatry, patients are made aware of the above shortfall and liability within the terms and conditions of booking. BUPA fund £45 for an initial consultation and £25 for a follow up consultation.
18. South West Podiatry may change the price of our services at any given time. The company will notify existing patients via email and publish a notice at reception at least 10 days before a price change. If you wish to cancel an existing consultation, please notify us via telephone or email at least 24 hours prior to a scheduled consultation. If you wish to attend your consultation, this will be charged under the new pricing structure.
19. As a new patient you will be asked to complete a digital consent form, you would be digitally signing and agreeing to the above statements in line with South West Podiatry’s terms and conditions. If you have any questions about the above please contact us. We may not be able to review you within our clinic if you fail to complete and submit this form.

Home visit - New Patient Form

How to book:

Insurance and Fees:

Booking terms and conditions:

Create or log in to your patient portal to book an appointment: