Mobile Foot Care Client Information & Service Overview

Mobile Foot Care Client Information & Service Overview

Provide your details for in-home foot care services
Welcome to Heart and Sole Foot Care! We provide gentle, mobile foot care services for seniors and adults who prefer in-home visits.Our services are cosmetic and preventative only — we do not diagnose, treat, or prescribe for medical conditions. We are happy to contact your primary care provider to help with a podiatry referral if needed. Please complete this short form so we can get to know you and ensure your comfort during your visit.
Client Information

Tell us about yourself so we can provide the best service.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Facility Address and Name*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone CallText MessageEmail
About You

Your health background helps us ensure your safety and comfort.
DiabetesCirculation issues (swelling, varicose veins, etc.)Neuropathy or numbness in feetRecent foot surgery or injuryNone of the above
YesNo
If yes, please provide their name and contact (optional)
ReferralFlyer or business cardSocial mediaFriend or familyOther
Our Cosmetic Foot Care Services Include:
- Nail trimming and shaping
- Gentle callus and dry skin reduction
- Moisturizing foot massage
- Foot health education and home care tips

Please note: We do not diagnose, treat, or manage medical conditions. If we notice anything that may need medical attention, we will refer you to a licensed podiatrist.
Consent & Acknowledgment

Please read and acknowledge the following before submitting.
Signature*

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Client Acknowledgment

I understand that Heart and Sole Foot Care provides non-medical, cosmetic foot care services only.I acknowledge that these services are not a substitute for medical treatment, and I will seek professional medical advice from a licensed podiatrist or physician for any concerns regarding infections, wounds, or other medical conditions.I consent to receive mobile foot care services at my home or designated location.
Date*

MonthDayYear
Date
Thank you for completing this form! We’ll contact you soon to schedule your first appointment and answer any questions you may have.
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Mobile Foot Care Client Information & Service Overview

Client Information

About You

Consent & Acknowledgment