Rain City Foot Care New Patient Intake Form Save time by completing this form online. All info is safe and secure. Name * First Name Last Name Date of Birth * Email * Address * Phone * Phone number of where to reach patient or person responsible for scheduling (###) ### #### Describe the living arrangement where the patient lives * Describe if the patient lives independently, in an Adult Family Home, Skilled Nursing Facility, or other. If in a facility, who should we contact to schedule foot care? Emergency Contact Name and Phone * Please add the name and phone number of your emergency contact. Financially Responsible Contact Info (if not self)? * Enter name / phone / email of financially responsible person- can write "same as above" if it is the same as your emergency contact or "self" How soon do you want to schedule? Do you have a day or time preference? * Do you have a recliner for foot care? If not, no worries! I will bring a foot rest When was the last routine foot care that you are aware of? Can be approximate date if unsure MM DD YYYY Does the patient have any mobility issues? * Describe if patient is ambulatory, or uses a wheelchair, walker, cane or is bed bound. Does the patient have any allergies? * Such as to Sulfa drugs or Latex? Write None if there are no known allergies Is the patient on blood thinners? * If so, what is the name of the medication? Does the patient have diabetes? * If yes, are they insulin dependent, controlled with diet, or oral meds? Does the patient have skin or vascular issues to be aware of? * Does the patient have any neuropathy (numbness) concerns? * Does the patient have any cognitive impairments such as dementia? * Describe any other health related issues here that the Foot Care RN should be aware of: * Anything else to know? How did you hear about us? General Info & Consent to Treatment 1. Routine Foot Care (RFC)- Consists of toenail trimming/debulking, reduction of corn/calluses, removal of the problematic area of an ingrown toenail, provide padding for comfort measures (some padding may have a small additional fee), foot & lower leg lotion/massage, foot care education, and referral to an appropriate provider, if necessary. RFC should be maintained every 6-8 weeks. There are risks with RFC including discomfort, bleeding, abrasions, and redness that may occur to toes/feet. The benefit of treatment is that my/the client's overall foot health will be improved by the care rendered. * Agreed 2. Limitation of Services- No other medical exam, diagnosis or treatment will be performed by the FCN. * Agreed 3. Privacy / HIPAA- Health records and personal information are protected and will not be released without permission. You may request copies at any time. My foot care nurse may take photos for my medical record, for educational or marketing purposes which will be confidentially kept. * Agreed 4. Fees- The initial visit for a foot care session is $125 and ongoing visits are $100 (up to an hour). Each additional 15 minutes is $20. If a care facility requires a progress note, or any other written report, an additional $10 report fee will be added to the above total. Most sessions can be completed in 45 minutes. Exceptional cases or initial cases may require more time or a second appt. * Agreed 5. Payment- Cash, Check, Cash App, Zelle, or Venmo are acceptable forms of payment and is due at time of service. A detailed receipt will be provided upon request. * Agreed 6. Insurance Coverage- RFC is not a service that is generally covered by Medicaid or other insurance. The FCN is unable to submit claims to insurance carriers however I can issue a "superbill" upon request, several clients have reported success submitting these to their insurance carriers for reimbursement. * Agreed Info for POAs: If you are managing payments for a loved one and aren't on site to make payment to FCN at time of services, a credit card authorization form will be required. This will be emailed to you before scheduling. See below for more details. * Due to the increased amount of admin time used for following up on unpaid invoices, Rain City Foot Care is now requiring a Credit Card Authorization form to be kept on file for all individuals who are paying for another person's foot care. The credit card will be automatically charged by Rain City Foot Care after service is provided and a paid invoice will be emailed to the POA. Rain City Foot Care is a nurse-owned and operated business without additional staff to assist with admin tasks. Thank you for understanding. Agreed 7. Permission & Consent- I acknowledge that I understand these statements, they have been explained to me in a way that I understand. My signature below indicates that I understand the aforementioned information and agree to treatment. * Please type your name and today's date below. Thank you for filling out this intake form online! Rain City Foot Care will be reach out to you no later than 24 hours to schedule your initial appt. We look forward to working with you and assisting you with your routine foot care needs! Thank you!
