Fields marked with an * are required
Please describe the issue you have by answering the following:
- The location of the issue
- When did the issue start
- What were you doing when you first noticed the problem
- What makes the problem worse
- What makes the problem better
- When do you notice the problem?
- Type of pain (burning, sharp, throbbing, aching,
- Stabbing, numbness, tingling)
- Pain level out of 10 (0=no pain 10=excruciating)
- How many times per week do you experience the pain?
By completing and submitting this form you agree to your own or if appropriate, your child's (under16) assessment/consultation by the podiatrist. Following the assessment, the podiatrist will provide you and your child with information about any proposed treatments and you will be given the opportunity to ask any questions. Please do not hesitate to ask your healthcare practitioner about any aspect of the proposed treatment before, during and after the treatment.
You are able to end the consultation at any point. Please note we do have a cancelation policy. You will not be refunded for any missed appointments or cancelations, you may re-schedule giving 24 hours’ notice, if l re-scheduling giving less than 24hours notice you will be charged. Terms and conditions
Please continue to the next step to make payment of $79.