Patient’s Consent

I hereby allow and consent to examination and treatment by the Chiropodist and allow photographs of treatment areas to be taken for the purposes of monitoring

I consent/allow the Chiropodist to contact my physician for any pertinent information required relating to my treatment or medical information

I consent/allow the Chiropodist to send my physician or healthcare professional a report regarding my foot exam and treatment plan

I understand that I am financially responsible for all charges whether covered by my health insurance plan or not. I understand that service fees are payable at the time service is provided.