Consent Form
CONSENT FOR FOOTCARE NURSING TREATMENT
Private Pay to Patients
Permission is hereby granted to Certified Foot Care Nurse Sara Ste-Croix RN BScN to facilitate the provision of foot care service and procedures as may be deemed necessary. I understand that this will include foot care examinations and service including toenail, corn and callus care, patient education, and appropriate referrals for other indicated treatment. Failure to maintain health through proper nail and skin care can reduce mobility, cause foot discomfort, and lead to skin and nail disorders. As with any treatment that requires the use of sharp instruments, there is a small risk of injury and infection to the surrounding tissue while trimming and filing. Extreme care and caution will be used at all times.
I understand that these services will NOT be billed to insurance providers. I agree to pay the provider the amount of the service being provided:
- $70 Initial visit
- $60 Follow up treatment
- $15 Fingernail clipping (add on)
- $10 Nail polish application (add on)
Payment to be made in cash or E-transfer to sara@lakeviewfootcare.ca
Payment to be made after service is complete, at appointment
If payment not received within 30 days a $10 fee will be added to account, and every month after appointment.
By signing below, I certify that I have read the informed consent, and I hereby request and give consent for foot care services to be provided by Sara Ste-Croix RN, BScN.