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Intake Form

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 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 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.
We have contracts with facilities throughout Niagara
*All rates and further information can be found on the Niagara Mobile Foot Care side of the website.
If yes selected please provide, the client's information below
All rates, procedures, late payment fees, etc can be found on the Niagara Mobile Foot Care side of the website.
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.
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.
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?