Allied Foot Specialists

The front side of the body is called the anterior and the back side of the body is the posterior.

Wear clean socks or stockings. Wear shoes made of leather or canvas.

Allied Foot Specialists
Comprehensive Medical & Surgical Management of the Foot

info@alliedfootspecialists.com

Podiatric Medicine	Family Foot Health	Foot Surgery
Sports Medicine	Diabetic Foot Care	Custom Orthotics

Offices throughout the Lower Mainland and British Columbia Serving:

Vancouver, Richmond, Burnaby, Whistler & Fort St. John:
#404 - 750 W. Broadway
Vancouver, BC V5Z 1H3
get map

Delta, Surrey, Langley & White Rock:
#203 - 8425 120th St.
Delta, BC V4C 6R2
get map

Phone for an office nearest you 604-878-FEET (3338)
F or calls outside the lower mainland Toll Free 1-877 878 FEET (3338)

You do not need a referral from your family doctor to see a podiatrist.

Patient Registration Form
Please fill out the online form or download a PDF of the form here.

All information provided is kept private and confidential and is for our office use only.

* indicates optional information

Which office do you prefer?

Delta, Surrey, White Rock, Langley
Tel: 604-878-FEET (3338)

Vancouver, Richmond, Burnaby, Whistler
Tel: 604-878-FEET (3338)

Name:

Gender:

Male
Female

Age:

Address:

City:

Province/State:

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Home Phone:

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Work Phone: *

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Cell Phone: *

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Email: *

Birth date (mo/day/yr):

Occupation:

Height:

Weight:

Shoe Size:

Family Doctor:

Family Doctor Phone: *

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Spouse/Partner/Guardian: *

Spouse/Partner/Guardian Phone: *

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State the nature of your visit:

Whom may we thank for referring to the office?

Family Doctor
Internet/Website
Yellow Pages
Friend
Advertisement
Health Care Professional
Other

Do you have prolonged bleeding after a cut?

Yes
No

Do you smoke?

Yes
No

Quantity:
How long?

Do you drink alcohol?

Yes
No

Quantity:

Do you have DIABETES?

Yes
No

Diagnosed:

Does anyone in the family have diabetes?

Yes
No

Who:

Current Medications:

Allergies to medications or food:

Have you ever been tested for HIV?

Yes
No

If yes, positive or negative:

Have you ever had Hepatitis?

Yes
No

Which type?

Serious illness or operations within the last 5 years?

Yes
No

Describe:

Previous foot injuries/foot surgery?

Yes
No

Do you have, or have you ever had:

Heart trouble
Eye problems
Arthritis
Asthma
Rheumatic fever
Epilepsy
Kidney problems
Liver problems
Stomach problems
High blood pressure
Faint easily