PERSONAL AND CONFIDENTIAL

Informed Consent to Podiatry Treatment

I hereby request and consent to the performance of podiatry treatment and other podiatry procedures including various modes of physical therapy by the podiatrist and/or anyone working in this clinic authorized by the podiatrist.

I further understand and am informed that, as in all health care, in the practice of podiatry there are some slight risks to treatment, including, but not limited to pain, swelling, infection. I do not expect the podiatrist to be able to anticipate and explain all the risks and complications and I wish to rely on the podiatrist to exercise good judgment during the course or the procedure, based on the facts then known and is in my best interest.

If at any time during the course of treatment I wish to withdraw my consent, I may do so.

For collection and use of personal information as included in this patient file, be assured privacy policies comply with legislation and standards set the Nova Scotia Podiatry Association. Only necessary information is collected and information only shared with your consent.

If you consent to this information, please click one of the links below to complete the intake form for your respective office.

If you would prefer to use the PDF version of the intake form