If you do not wish to fill out the form, please call (905) 708-9817 Online Intake Form Welcome to Our Foot Care Services! Before completing the online intake form, please review our website for important information on costs, policies, and procedures. Once submitted, our foot care team will email you to schedule your appointment. Your information is confidential and shared only within our team.Please enable JavaScript in your browser to complete this form.Client Type (Please select one)New Client – Residential HomePrevious Residential ClientClient lives in Retirement Home, Group Home, LTC*Note: We currently do not visit NHS hospitals, only Shaver Hospital.If you selected LTC, Retirement Home, or Group Home, please specify the name of the facility: (We have contracts with various facilities throughout Niagara; naming the facility helps us coordinate care if a contract already exists.)Service Requests – Residential ClientsAdvanced Nursing Care – $50/client (St. Catharines), $65/client (other areas)Basic PSW Care – $35/client (St. Catharines), $50/client (other areas)*I do not know – please contact me TRIAGE is required for Basic PSW Care. More information available on the Niagara Mobile Foot Care website.Service Requests – Facility Clients (LTC, Retirement, Shaver Hospital)Clinic Visit: $35/client (scheduled every 6 weeks)In-Apartment Visit – St. Catharines: Advanced Nursing Care $45/clientIn-Apartment Visit – Virgil Area: Advanced Nursing Care $60/clientShaver Hospital Visit: $60/client + parking fees ($2.50/hour)I do not know please contact me Detailed rates and information are available on the website.Additional ServicesBasic Finger Nail Care – $15I am interested Basic Foot Care Aesthetics (Additional costs) ***See website for more details.Main Contact NameFirstLastMain Contact Email Main Contact Phone NumberIs the foot care for someone else?YesNoIf yes, provide client information:Name of ClientFirstLastPhone Number of ClientAddress of Client Payment AcknowledgmentYes – I will pay by cash at the visitYes – I will pay by e-transfer after the visitYes – I will pay by cheque at the visitYes – I have DVA (Veterans Affairs Canada)No – please send me further information All rates, procedures, late fees, etc., are available on the Niagara Mobile Foot Care website.Provider Competency Acknowledgment (Check all the apply) I am aware that the foot care providers (PSW, RN, RPN) have completed training in therapeutic, non-invasive foot care.I acknowledge providers use only single-use or sterile equipment and follow strict Public Health Guidelines.I understand that pedicure services are NOT offered. Please acknowledge that our foot care providers (PSW, RN, RPN) have completed training in therapeutic, non-invasive foot care and use only single-use or sterile equipment/supplies, following strict Public Health Guidelines. We do not offer pedicure services.Cancellation / No-Show PolicyI am aware of the Cancellation/No-Show Policy. Appointments not canceled 24 hours prior to the scheduled time will incur a $20 fee, applied to the next appointment.Health History / Triage (Please select all that apply)Client is diabetic (Type I / Type II)Client is on blood thinnersClient has dementia/cognitive declineClient has a history of amputationsClient has current wound(s) to toes, feet, or lower legClient has thick nails / possible fungal infection*Client has possible ingrown toenail*Client has moderate/severe lower leg swellingClient has blood flow concerns to lower legsI prefer not to answer – please contact me to triageThese questions help ensure placement with the appropriate foot care provider. Providers work within their scope and will provide recommendations/referrals if necessary.Additional CommentsRespiratory Illness Self-AssessmentYes – the household is clearNo – the household is not clear; please postpone careEmailSubmit
