Intake Form for Foot Care AppointmentPlease enable JavaScript in your browser to complete this form.Contact 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 ClientAdditional CommentsI am aware of the cancellation Policy 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. Public Health Infection Preventing Self Screening QuestionsThe individual requiring care DOES NOT have any current signs and symptoms of acute respiratory infectionThe individual requiring care DOES have a new/worse cough or shortness of breath, travelled in the last 14 days and/or has had contact with a sick person who has travelled in the last 14 days? (answer in comment section)As per public health guidelines Niagara Mobile Foot Care must screen clients for signs and symptoms of acute respiratory infection. Comment Please select the area of Niagara that the client is located. (Availability updated daily).St.Catharines (Services on hold until further notice- not taking any new clients at this time) Cost $35/client (Increasing $5 April 1 2020) Other - We can connect you with other nurses in the community Other regions of Niagara, we can 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, WainfleetPhoneSubmit
