Foot Facts
About 56,000 people a year lose their foot or leg to diabetes.
Foot Care
Bring your own clean instruments to a nail salon and ensure that they are used by your manicurist.
 
Contact Us

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:
    Postal/Zip Code:
    Home Phone:

    ( ) -

    Work Phone: * ( ) -
    Cell Phone: * ( ) -
    Email: *
    Birth date (mo/day/yr):
    Occupation:
    Height:
    Weight:
    Shoe Size:
    Family Doctor:
    Family Doctor Phone: * ( ) -
    Spouse/Partner/Guardian: *
    Spouse/Partner/Guardian Phone: * ( ) -
    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
       

     



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    info@alliedfootspecialists.com