If you do not wish to fill out the form, please call (905) 708-9817 Online Intake Form Welcome to Our Foot Care Services Please review our website for details on costs, policies, and procedures before completing the intake form. Once submitted, our team will contact you by email to schedule your appointment. All information provided is confidential and shared only within our care 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 visit Shaver Hospital only and do not provide services at NHS hospitals.**If applicable, please provide the name of the LTC, Retirement Home, or Group Home facility.**(We work with many facilities across Niagara; providing the facility name helps us coordinate care if a contract is already in place.)Service Requests – Residential ClientsAdvanced Nursing Care: $50 per visit (St. Catharines) $65 per visit (other areas)Basic PSW Care: $35 per visit (St. Catharines) $50 per visit (other areas)I do not know – please contact meTriage is required before booking Basic PSW Care.Facility Clients (LTC, Retirement Homes, Shaver Hospital)Clinic Visit: $35 per client (typically every 6 weeks)In-Apartment Visit (St. Catharines): $45 per clientIn-Apartment Visit (Virgil Area): $60 per clientShaver Hospital Visit: $60 per client + parking feesI do not know please contact me Detailed rates and information are available on the website.Additional ServicesBasic Finger Nail Care: $15 (add-on service)Basic Foot Care Aesthetics: Available (additional cost) ***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 Options - Payment can be made by:Cash at the visitCheque at the visitE-transfer after the visitVeterans Affairs (DVA) coverage (if applicable)No – please send me further informationFull rates, policies, and fees are available on the Niagara Mobile Foot Care website.Provider Competency Acknowledgment Clients confirm that: Foot care providers (PSW, RN, RPN) are trained in therapeutic, non-invasive foot care. Providers use single-use or sterile equipment and follow Public Health guidelines. Pedicure services are not offered Cancellation / No-Show PolicyClient confirms that: Appointments must be canceled at least 24 hours in advance Missed or late cancellations will result in a $20 fee, applied to the next appointment 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 CommentsSafety Screening : A respiratory illness self-assessment is required before visits:Household clear – appointment proceedsHousehold not clear – care will be postponed CommentSubmit
