IN HOME FOOT CARE FORM – Sole Centered Foot Care

Sign Up For In-Home Foot Care Services

Please fill out this form and based on the following information we will coordinate with you via phone for availability options.

I am contacting you because I need in-home foot care services for ...
- Myself
- Someone I care for
I am Interested in...
- Foot Care
- Ingrown Toenail Care
- Fungal Nail Treatment
- Compression Sock Fitting
Your Name*
First Last
The Patients Name*
First Last
Patients Date Of Birth*
Will you be the main point of contact for booking and billing?*
- Yes, I will be managing booking and billing on the patients behalf.
- No, please book appointments nad manage billing with the patient directly.
Your Phone*
Patient Phone*
Billing*
- I will manage payment on behalf of the patient
- I will manage payment for myself
Patient Home Address*
Street Address City Postal Code
Your Email*
(Preferred But Optional)
Patient Email
(Preferred But Optional)
Please Describe Parking Availability*
Please note that parking fee's will be added as additional costs where applicable.
- Driveway Parking (Free)
- Street Parking (Paid)
- Street Parking (Free)
- Parking Lot (Paid)
- Parking Lot (Visitors)
- Hospital Parking
What is your preferred method of payment?*
- Credit Card
- Debit Card
- Email Money Transfer
- Cash
- Cheque
Do you have Veterans' Affairs Insurance?
- Yes
- N/A
Veteran Affairs "K Number"
Comments*
Please tell us more about your foot care concerns or other information you feel is relevant prior to your home visit.
CLICK HERE SO I KNOW YOU ARE A REAL PERSON

Δ

Phone: (343) 558-0909

Email: info@solecentered.ca

Navigation

Scroll to Top