Compassionate Soles Client Intake & Consent Form

Compassionate Soles — Client Intake & Consent Form

Client intake and consent form. Complete the fields in the order shown, matching the source DOCX as closely as practical.
Client Information
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact
Emergency Contact Name

First NameLast Name
Emergency Contact Relation
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Appointment and Pet Information
Appointment Type
Do you have any pets?
Mobile Visit Pet Policy

To maintain the highest standards of cleanliness, infection prevention, and safety for all clients, Compassionate Soles is unable to provide mobile services in homes where pets are present in the service area during the appointment.

Pet hair, dander, and unexpected animal movement can compromise the sterile field required for our instruments, supplies, and clinical-grade foot care procedures. For this reason, if pet(s) are present in the home, mobile services may be declined or discontinued at the discretion of Compassionate Soles if pet(s) can’t be secured in an area away from where the service is being provided in the home.

Clients with pets are welcome to receive services at our private suite location, where we can ensure a controlled environment that meets our infection prevention and safety standards.

We appreciate your understanding and cooperation as we work to provide safe, compassionate, and professional care to every client.
Service Preferences
Service Type Being Requested

Other
Finishing Type
Preferred Color
Podiatrist Information
Do you currently see a podiatrist?
Podiatrist Name
Podiatrist Phone
Please enter a valid phone number.Format: (000) 000-0000.
Health Conditions and Medications
Health Conditions

Other
Current Medications

Other
Allergies

Other
Foot Concerns and Consents
Primary Foot Concerns Today

Other Foot Concern
Upload photos of your feet

Please upload clear, well-lit photo of both feet, including the tops of each foot and close-up images of all toenails. If your concern involves calluses, cracked heels, pain, or skin issues on the bottom of your feet, please also include clear photos of the soles.
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Photo Consent – Service Records / Medical Communication
Photo Consent – Marketing & Education
Text Message Consent – Informational Messages
Text Message Consent – Marketing Messages
Appointment Policies & Client Acknowledgment

To provide the highest level of service and ensure appointment availability for all clients, Compassionate Soles requires advance notice for appointment changes and cancellations.

Appointment Confirmation
Clients are responsible for confirming and attending their scheduled appointments. Appointment reminders may be sent as a courtesy; however, failure to receive a reminder does not waive client responsibility for the appointment.

Cancellation Policy
Appointments canceled with less than 24 hours' notice may be subject to a cancellation fee.

No-Show Policy
A no-show occurs when a client fails to attend a scheduled appointment without providing notice. No-show appointments may be subject to a fee of up to 100% of the scheduled service amount and may require prepayment before future appointments can be scheduled.

Late Arrival Policy
Late arrivals may result in a shortened service to avoid delaying other appointments. If a client arrives more than 15 minutes late, the appointment may need to be rescheduled and may be subject to a cancellation fee.

Mobile Appointment Policy
For mobile appointments, the client or responsible party must ensure that:

The client is present and available at the scheduled appointment time.
A safe, clean, and suitable workspace is available.
Pets are secured and not present in the treatment area during the appointment.
Any required caregiver or responsible party is available if needed.
If Compassionate Soles arrives and services cannot be performed due to an unsafe environment, client unavailability, or undisclosed conditions that prevent safe care, a trip fee and/or cancellation fee may apply.

Payment Policy
Payment is due at the time services are rendered unless prior arrangements have been made. Deposits are currently not required however for clients that constantly reschedule a non-refundable deposit may be required but it can be applied towards the rescheduled appointment when proper notice is provided.

Right to Decline Services
Compassionate Soles reserves the right to decline, discontinue, or postpone services when:

Conditions appear outside the scope of practice.
Medical clearance is required.
Services cannot be performed safely.
Client behavior is inappropriate, threatening, or disrespectful.

By submitting this intake form at the bottom I acknowledge that I have read and agree to the appointment policies.
Client Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Compassionate Soles — Client Intake & Consent Form

Client Information

Emergency Contact

Appointment and Pet Information

Service Preferences

Podiatrist Information

Health Conditions and Medications

Foot Concerns and Consents