Niagara Mobile Foot Care is now booking appointments for foot care with limited availability. 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 FormFollowing 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 enable JavaScript in your browser to complete this form.Please select oneNew Client Residential Home Previous Residential ClientNew Client LTC, Retirement Home, Group HomeNiagara Mobile Foot Care is booking for the week of April 15th 2021If you selected LTC, Retirement Home, Group Home, Please Specify We have contracts with facilities throughout Niagara Please select all that apply St.Catharines - Residential House Facility/LTC/Retirement/Group Home (Please contact me with rate)Other - We can connect you with other foot care nurses in the community In other regions of Niagara, you can be connected with an independent foot care nurse that will self schedule your appointment (Rates Vary). Examples-Thorold, Niagara on the lake, Welland, Port Colborne/Welland Port, St. Davids, Niagara Falls, Stevensville/Ridgeway, Vineland, Grimsby, WainfleetContact NameFirstLastContact Email Contact Phone NumberIs the foot care for someone else?Yes No If yes selected please provide, the client's information below Name of ClientFirstLastPhone Number of ClientAddress of ClientI am aware of the Cancellation/ No Show Policy (during COVID-19 we are waving this cancellation cost- please always call and cancel your appointment if you are feeling unwell) YesAppointments 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. Does the client have any urgent concerns? Appointments will be triaged based of urgent concerns. The client is in need of routine nail care, not an urgent concernThe client is experiencing the verbal expression of pain or detriment, without infection present (if infection present refer to family Dr.)Due to COVID-19 we have limited capacity per day for residential client appointments. Additional CommentsThe individual completing the form has completed the self assessment for COVID-19 screener (see questions below) *Yes the household is clearNo the household is not clear, please postpone careThe 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?PhoneSubmit
