Calgary Foot Clinic Intake Form

Unit 3225, 40 Christie Park View SW Calgary, AB T3H 6E7

(Second Floor of Building 3000)

Phone: (403) 266-2700 Fax: (403) 266-2900
Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
Date
Alberta Health Care Number
If you do not have Alberta Health Care, additional fees will apply.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell or Preferred Phone Number

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
Do you consent for us to send you appointment reminders via Text, Email or Voice Messages?
Occupation:
Weight
Height
Shoe Size
Is your foot problem a work-related injury?
Emergency Contact (Name and Relationship)
Emergency Contact Phone Number

Area CodePhone Number
How did you hear about our office?
Medical Information
Name of Family Physician:
Family Physician Telephone Number:
Name of Former Podiatrist (if any):
Approximate Date of Last Podiatry Visit:

MonthDayYear
Date
Briefly describe your foot problems:
What medicines do you take regularly?
Please list any operations:
Do you have Diabetes?
If Yes to above question, what type?
Please indicate if you have or have had any of the following:
Please list any Allergies to Drugs, Medicines, or Materials:
Please describe any other major health problems or additional health information:
Signature:
Date:

MonthDayYear
Date
Should be Empty: