Full Name (person to receive footcare)
First Name
Last Name
Name of person filling out form (If different from above)
First Name
Last Name
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Address where footcare is to be provided.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Let us know a date and time of preference and we will get back to you?
*
Details: reason for appointment?
*
Example: Callus, corns, ingrown nail, nail trimming?
Please check off all health conditions that apply to you
Diabetes
Arthritis
Heart disease
Lung disease
Issues with circulation
HIV
Hepatitis
Kidney disease
Neurological disease
Cancer
***Important
* Please Fill out the form in it’s entirety. All payments are to be made by cash, cheque or etransfer on day of appointment. ALL APPOINTMENT INQUIRIES HAVE TO BE APPROVED BEFORE THEY ARE CONFIRMED. I will reach out to you to confirm your appointment. Thank you so much for your Inquiry! I look forward to meeting you!
Submit
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