Rain City Foot Care Intake Form for Residents of Edmonds Senior Village and Edmonds Landing Save time by completing this form online. All info is safe and secure. Name * First Name Last Name Date of Birth * Email * Phone # * Phone number of where to reach patient or person responsible for scheduling (###) ### #### Edmonds Landing or Edmonds Senior Village? * Apartment # * 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 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? * Describe any other health related issues here that the Foot Care RN should be aware of: * Anything else to know? 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 group rate for foot care is $75 per session. Appointments are 30 minutes long. For foot care requring longer than 30 minutes, there will be additional fees: $15 per 20 minutes. * Agreed 5. Payment- Cash or Check and is due at time of service. Please have payment ready in order for Foot Care RN to stay on time. 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. Please contact your podiatrist if you would rather utilize possible foot care benefits available to you through your insurance provider. See FAQ page for more information about insurance and foot care. * Agreed 8. 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! Please click the blue "send" button below to submit form.We look forward to working with you and assisting you with your routine foot care needs! Thank you!
