CONSENT FOR TREATMENT

I ________________________________ authorize Peace Region Mobile Foot Care to request information regarding foot care. None of this information will be shared with any other individual except other medical professionals.

I am aware that some procedures may involve a very limited risk of infection, the creation of minor bleeding points or minimal pain and discomfort.

CONSENT FOR THE COST OF SERVICES

We do not bill directly to insurance companies. You are responsible to pay for all visits, services and products. A receipt will be issued that can be used for submission to your insurance company of for your own personal records and income tax. Peace Region Mobile Foot Care will accept the following payment options: Cash or cheque. The cost per visit is $80.00 per hour/ $60 half a hour. When you own your own instruments the cost per visit is $65 per hour/ $45 per half hour.

CONSENT FOR PERSONAL INFORMATION

I understand that by receiving foot care services, Peace Region Mobile Foot Care will collect some personal information about me. Only necessary information related to foot care will be collected. We only share information with your consent. Our privacy protocols comply with legislation, standards of our regulatory body, the College for Licensed Practical Nurses Association.

SUMMARY

I have read and understand all information on the Peace Region Mobile Foot Care consent form. I have been given a chance to ask any questions I have about the treatment, cost of services and collecting of personal information.

SIGNATURE ________________________________

PRINT NAME ___________________________________________

DATE: ___________________________________

                                                           Peace Region Mobile Foot Care