Intake Form – Welcome to Niagara School of Foot Care/ Niagara Mobile Foot Care

Before filling out the intake form, please go to Niagara Mobile Foot Care Services to ensure you are aware of our what services are available, the costs, policies and procedures that are place for foot care appointments.

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

Please ensure you read the information provided on the website, before filling out the form, so you are aware of all costs, policies and procedures. 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.

Please select one

New Client Residential Home
Previous Residential Client
Client lives in Retirement Home, Group Home, LTC*

*Please speak with the Long Term Care facility to complete the consent form at the home. All of our contracted LTC homes have a copy of the paper consent on the unit or at the main office.

If you selected LTC, retirement, group home, please specify the name of the home

We have contracts with facilities throughout Niagara

Contact Name

First

Last

Contact Email

Contact Phone Number

Is the foot care for someone else?

If yes selected please provide, the client's information below

Name of Client

First

Last

Phone Number of Client

Address of Client

I am aware that there is a cost for foot care services, which vary depending on services needed.

Yes I will pay by cash at the time of the visit
Yes I will pay by e-transfer after the visit
Yes I will pay by cheque at the time of the visit
I have DVA (Veterans Affairs Canada)
No I am not aware of the costs, please send me further information.

All rates, procedures, late payment fees, etc can be found on the Niagara Mobile Foot Care side of the website.

I am aware the the foot care providers (PSW, RN, RPN) have completed training in therapeutic, non invasive foot care and use only single use or sterile equipment/ supplies and follow strict Public Health Guidelines for medical foot care. We do not soak feet, we are not a pedicure service.

Yes I am aware
No I am not, please send me more information on your services.

I am aware of the Cancellation/ No Show Policy (Please always call and cancel your appointment if you are feeling unwell)

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.

Health History Triage (Please select all that apply)

Client is diabetic (Type I, Type II)
Client is on blood thinners
Client has a history of amputations
Client has current wound to toes, feet and/or lower leg
Client has thick nails, possibly fungal*
Client has a possible ingrown toe nail*
Client has a history of mod/severe lower leg swelling
Client has a history of blood flow concerns to their lower leg
I prefer not to answer, please contact me to triage

We ask these questions to ensure you are placed with the appropriate foot care provider. *The foot care providers cannot diagnose and prescribe medications. All foot care providers work within their scope of practice and will offer recommendations and referrals if necessary.

Additional Comments

The individual completing the form has completed the self assessment for respiratory illness screener (see questions below)

Yes the household is clear
No the household is not clear, please postpone care

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 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?

Name