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ABOUT US
SERVICES
FAQ
ARTICLES
CONTACT US
CLINICS
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
Your Name
*
First
Last
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 Address
*
Please invoice me at my address
Please invoice the patient at their address
Your Billing Address
*
Street Address
City
Postal Code
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
Veteran Affairs
Please indicate the type of veteran affairs insurance you have
Standard Veteran Affairs Benefits
Veterans Independant Program (VIP)
Have you been approved for in-home foot care services?
Yes
No
Unsure
Please Call 1-866-522-2122 for more information regarding your plan coverage.
I will call and follow up with the nurse later.
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.
