Thrive Foot Care
Intake & Consent Form
Please complete this form before receiving nursing foot care services from Eveline v. Haastert, RN, BsN, Advanced Foot Care Nurse.
This form collects client information, medical history, and consent details used to prepare for foot care services and treatment. For urgent medical concerns, contact a physician, urgent care clinic, emergency service, or another appropriate healthcare provider.
Before you begin
Complete required fields
Fields marked with an asterisk are required.
Use N/A where needed
If a required question does not apply, enter “N/A”.
Include relevant details
Add health information that may affect foot care.
Questions?
Call 604-483-8378 before submitting.
Client information and consent
The information submitted through this form is used for foot care preparation, appointment communication, treatment records, and client care.