FEET IN FOCUS Intake Form

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Prior to filling out the intake form please be sure to review all information provided on our website to ensure you are aware of all costs, services available, the areas we service, and the policies and procedures for foot care appointments. Following the completion of the form, we will contact you to book your foot care appointment via email (or by phone if preferred). Please note this form is confidential and is only shared within the foot care team.

Email *

Please select one of the following: *

If you selected retirement home, group home, or long-term care home please specify the name of the home below

NEW Client - Residing in a Residential Home

Existing Client - Residing in a Residential Home

NEW Client - Residing in a Retirement Home, Group Home, Long-term Care (LTC)*

Existing Client - Residing in a Retirement Home, Group Home, Long-term Care (LTC)*

Other:

Required

Services Requested: *

Please select all that apply:

Tillsonburg Area - Residential Advanced Nursing Foot Care Services ($70 - Tillsonburg Only)

All Other Areas Serviced - Residential Advanced Nursing Foot Care Services ($80 - Please See List of Serviced Areas)

Add Fingernail Care(+$15) Please Note: This service is a quick trim and file, not a full manicure (no nail polish)

Other:

Required

Are you filling out this form to make a foot care appointment for someone other than yourself? *

Yes - Please complete the CLIENT section for the perspective client below and provide your information in the CONTACT section below

No - Only complete the CLIENT section below

CLIENT's Full Name (First and Last), Home Address, Email Address and Phone Number: *

Please complete information for the person who will be receiving foot care below:

CONTACT's Full Name (First and Last), Home Address, Email Address and Phone Number:

Please provide your information below if you are organizing a foot care appointment for someone other than yourself:

Who should be contacted to arrange foot care appointment details?

The Contact

The Client

Clear selection

Who is your current foot care provider? *

Myself - Independent Care

A Caregiver

A Professional Foot Care Provider (Podiatrist, Chiropodist, RN, RPN, PSW/HCA, etc)

No Recent Foot Care

Other:

Required

Have you ever received professional foot care? *

Please list reason(s) for requesting medical foot care and any foot problems or concerns you may have below: *

Health History: (Please Select ALL That Apply) *

These questions are asked to assist the nurse in determining your risk level and the level of care that may be required. *Please note nurses cannot diagnose or prescribe medications*. All foot care nurses work within their scope of practice and within their individual competencies which are based on knowledge, skill, judgement and comfort level. The nurse will offer a referral if the nurse deems necessary, or if requested.

Client is Diabetic (Type I, Type II)

Client Currently has Active Wound(s) to the Lower Extremity (toes, feet and/or lower leg)

Client has a History of Amputation(s) (That is NOT due to an ACCIDENT or INJURY)

Client takes Anticoagulant/Antiplatelet Medication "blood thinners" (For Example - but not limited to: Heparin,Warfarin/Coumadin, Xarelto/Rivaroxaban, Eliquis/Apixaban, Pradaxa, Lovenox, Savaysa, Aspirin)

Client has a Possible Ingrown Toenail* (That DOES NOT have any of the following signs and symptoms of infection)

Client has Thick Nails - Possibly Fungal*

Client has a History of Blood Flow Concerns to their Lower Extremities (A Diagnosis of Hypertension, Atherosclerosis, Arteriosclerosis, Heart Failure, Heart Attack, Stroke, Peripheral Artery Disease (PAD), and/or Edema are some diagnoses that may contribute to blood flow concerns)

Client has a History of Severe Lower Leg/Foot Edema (Swelling)

I Prefer not to Answer - Please Contact Me to Triage

None

Other:

Required

Nursing foot care is not well understood and often confused with aesthetic nail and foot care. We are NOT a pedicure service. Nursing foot care and all nursing practice is evidence-based, and foot soaks have been determined to NOT be best practice as they promote risk for infection. *

I understand a foot soak promotes risk for infection, and will NOT be a part of my foot care service. I also understand doing so myself prior to foot care treatment can promote risk of infection.

Please provide me with more information about risks involved with soaking feet

Other:

Required

I am aware there is a cost for nursing foot care services which MAY NOT be covered by my extended health insurance plan *

All rates for service can be found on the FEET IN FOCUS website under the 'More Information' tab

Yes, I am aware and understand payment for nursing foot care services are to be paid on the day of service to my foot care nurse by cash, cheque, or e-transfer

No, I am not aware of the costs. Please send me further information.

Additional Comments:

Signature *

I attest the above statements are accurate to the best of my knowledge and do not contain any false, incomplete, or misleading information.

YYYY

A copy of your responses will be emailed to the address you provided.

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