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Intake Form

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 All foot care appointments are triaged based of urgency. If you do not wish to fill out the form, please call (905) 708-9817 

Online Intake Form New Service
Following the completion of the form reception will contact you to set up the date and time of your appointment via email. The form is confidential and only shared within the foot care team.
We have contracts with facilities throughout Niagara
* Areas we do not serve- Port Colborne/Welland Port, Stevensville/Ridgeway, Fort Erie and Wainfleet. We can connect you with an independent foot care nurse that will self schedule your appointment (Rates Vary).
If yes selected please provide, the client's information below
Appointments that are not cancelled 24 hrs prior to your scheduled appointment will be subject to a cancellation fee of $20.00 (this includes same day cancellations and no shows). This fee will be added to your next appointment.
Due to COVID-19 we have limited capacity per day for residential client appointments.
The client(s) and household ( residence of individual needing foot care services) does not have a fever, new onset of cough, worsening chronic cough, shortness of breath, or difficulty breathing? The client(s) and or facility does not have one or more of the following symptoms: sore throat, runny nose/sneezing, nasal congestion, hoarse voice, difficulty swallowing, decrease or loss of sense of smell, chills, headaches, unexplained fatigue/malaise, diarrhea, abdominal pain, or nausea/vomiting? The client (s) or facility has not had close contact with anyone with acute respiratory Illness or traveled outside of Canada in the past 14 days? The client(s) and or facility has not been in close contact with anyone with acute respiratory illness in the past 14 days? If the client (s) or facility is over 65 years of age, are they experiencing any of the following: delirium, falls, acute functional decline, or worsening of chronic conditions?