Medical History Questionnaire

Medical History Questionnaire:

Prior to a scheduled new client consultation, please complete the online form below and click submit. You may also be prompted to update this form throughout your care within our service. As a Healthcare organisation we are required to collect and store accurate personal data and medical records for each client.

Please fill out the medical history form below and press submit. Please fill this online form out once prior to your consultation:

  • Clinical letters may be sent to your GP or referring clinician to keep your medical record updated. If you do not know your GP, please just add the GP practice name.
  • Please add your email address to process appointment confirmations, invoices and clinical letters.
  • Please add your mobile phone number to receive appointment confirmations and important information about your care.
  • Enter "Nil" if you do not take any prescribed medication.
  • Enter "Nil" if you are medically fit and well.
    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.
  • If you are attending via Private Medical Insurance (BUPA, WPA, AVIVA, CIGNA, Vitality, Simply Health ), please input the following: -Authorisation code -Membership number -Excess amount

Clinic locations:

We have several clinical locations and also offer online video consultations. Please see the about us section for further information.  *On-site diagnostic ultrasound is available at Earlsfield and Maidenhead only

How to book:

Schedule your consultation online click here:  BOOK ONLINE.  Alternatively, speak to our friendly booking team, Monday-Friday 9am-5pm: 02071646607.

Insurance and Fees:

We accept most major private medical insurance companies including BUPA, Vitality, WPA, Cigna, AVIVA and Simply Health. A full list of our consultation fees including self-pay can be found here:  Insurance and Fees

Booking terms and conditions:

By submitting this form, you agree to South West Podiatry’s booking terms & conditions and consent for South West Podiatry to securely hold your medical record.