New clients

New client intake

Please complete this form before your first appointment, so your nurse can prepare for your visit.

Your answers go only to Bare Soles. When you submit the form, it is sent directly to our email inbox; this website does not keep a copy.
Also email a clear photo of your feet, taken in good light, to baresolesinc@outlook.com before your visit.
Prefer paper? Download the intake form (PDF) and email it to us.

Client identification

Full name

Date of birth

Sex (optional)

Primary phone

Home address

Past or current occupation (optional)

Appointment details

Where will the appointment take place?

Private home Hospital Retirement home Long-term care home or nursing home

Facility name (optional)

Room or bed number (optional)

I am a veteran and would like Bare Soles to bill Veterans Affairs Canada directly.

Current medications

List all current medications, including over-the-counter medications and supplements. (optional)

Wellness screening

Are you currently experiencing:

Respiratory or viral symptoms: fever, new or worsening cough, shortness of breath, sore throat, or loss of taste or smell?

Yes No

Recent falls, delirium, or a sudden decline in mobility?

Yes No

Consent and authorization

I certify that the information above is correct to the best of my knowledge. I understand that the foot care provider will perform assessments, nail and callus reduction, and provide health teaching.

Completed by

The client Power of attorney

Signature: type your full name

Date

New client intake

Thank you.