Please fill in and complete the New Patient Form to the side and click submit, prior to your appointment
New Patient Form
I understand that payment of the account is my responsibility and must be paid on the day of the consultation.
Jonathan Ellis Podiatry needs to collect information about you for the primary purpose of providing a quality service to you. In order to thoroughly assess, diagnose and provide therapy, we need to collect some personal information from you. If you do not provide this information; we may be unable to treat you. This information will also be used for:
I. The administrative purpose of running the practice;
II. Billing either directly or through an insurer or compensation agency;
III. Use within the practice if discussing or passing your case to another practitioner within the practice for your ongoing management;
IV. Disclosure of information to your doctors, other health professionals or to teachers to facilitate communication and best possible care for you; and
V. In the case of insurance or compensation claim it may be necessary to disclose and/or collect information that concerns your return to work to an insurer or your employer.
We do not disclose your personal information to overseas recipients.
To ensure the process of quality treatment provision, information about your assessment results and progress may be given to relevant other service providers, who are involved in your management. These may include your doctor, teachers, specialists, insurers, solicitors or employers.
I have read the above information and understand the reasons for the collection of my personal information and the ways in which the information may be used and disclosed and I agree to that use and disclosure.
I understand that it is my choice as to what information I provide and that withholding or falsifying information might act against the best interests of my assessment and therapy progress.
I am aware that I can access my personal and treatment information on request and if necessary, correct information that I believe to be inaccurate.
I understand that if, in exceptional circumstances, access is denied for legitimate purposes, that the reasons for this and possible remedies will be made available to me.