Please read the following Chiropody policy statements. By signing below, I am aware of/consent to the following statements:
I voluntarily request Andrea Ferguson (BHK, D.Ch and/or Melissa Allen (B.Sc., D.P.M, Marija Krstic (BHK, D.Ch) as my Chiropodist, to assess and treat my condition.
Iam aware of the chiropody service fees. I am aware that any chiropody fees are not covered by OHIP and that it is my responsibility to understand my extended health benefit details before seeking treatment. (Note: If you need help understanding your extended health benefits, please ask the administrative staff)
I hereby authorize payment directly to the business office of this practitioner for the surgical and/or medical benefits, if any, otherwise payable to me for services. I understand that I am financially responsible for any portion of my bill not covered by my insurance company.
I hereby authorize release of information and/or medical records of myself, to any treating physician or insurance company.
Cancellation policy: Due to the demand for chiropody care, we would appreciate 24 hours notice if you cannot make your scheduled appointment. If you fail to attend your scheduled appointment or do not give at least 4 hours notice before, on the third no show appointment a fee of $50 (cost of the visit) will be charged to you directly. Please note, if you are over 15 minutes late, the Chiropodist may not be able to see you and this will count as a no show.