Patient Intake / Consent Form We are dedicated to providing clinical mobile nursing care in Ottawa

1. Patient Information

2. Medical History

Please answer the following questions to help us assess your foot care needs:

3. Informed Consent

Please read and initial each section:

Treatment Consent: I voluntarily consent to receive mobile foot care services from SoleHealth. I understand that the service is performed by a qualified professional and involves the assessment and care of the foot and nail area. Although all care is performed using professional standard and infection control measures, foot care procedures carry minimal risks, but may include minor cut or bleeding, skin irritation, discomfort or sensitivity, infection and or the delayed healing (especially if diabetic or poor circulation). Services are not a substitute for medical treatment by a physician or podiatrist. I must inform the provider of any changes in my health status before each session. (Initial ________ )

Mobile Service Agreement: I acknowledge that this is a mobile service provided in my home/residence. I have provided a safe and accessible space for the practitioner to perform the service. (Initial ________ )

Risk Disclosure: I understand that while foot care is generally safe, complications such as skin irritation or minor bleeding may occur, particularly if I have compromised circulation or diabetes. I agree to notify the practitioner immediately if I experience pain or discomfort.

(Initial: _____ )

Privacy Policy: I understand that my personal health information will be collected and stored by SoleHealth solely for the purpose of my treatment and is protected under applicable privacy laws. (Initial: _____ )

Cancellation Policy: I understand that SoleHealth requires a minimum of [24/48] hours notice for any cancellations. Cancellations made within this window may be subject to a fee of $[Amount]. (Initial: _____ )

4. Patient Declaration

I confirm that the information provided above is accurate and complete to the best of my knowledge. I understand the nature of the services provided and have had the opportunity to ask questions.