Get In Touch With Us
Facility or Organization Name
*
Facility type
*
Church
Senior Center
Assisted Living/Personal Care
Community Organization
Other
Primary Contact Name & Title
*
Email Address
*
Phone
*
Time Available for Communication
Morning
Afternoon
Evening
Best Way of Communication
*
What best describes your interest in hosting a foot care day?
We'd like to host an on-site clinic for residents/members
We're planning a wellness event and want you there
We're interested in an ongoing partnership
We'd like more information
Event Location Address
City
State
Country
Country
Postal Code
Preferred time of event or clinic
*
Preferred length of event or clinic
3 hours
4 hours
5 hours
Estimated number of participants/residents
Space Available at Location
Private Room
Tables & Chairs
Electrical Outlets
Hand Washing Access
Your preferred way to fund Foot Care Days
Participant self-pay
Organization-sponsored
Grant-funded or subsidized
We'd like to explore options
Rate Structure
Flat Clinic Rate
Per Participant Rate
Time Block Rate
To Be Determined
Acknowledgments
*
I understand services provided are non-medical, preventative foot care and do not include wound care, infection treatment, or medical services.
I Agree
Name of Authorized Representative
Additional comments or questions
After you submit this form, a CareSteps representative will follow up with you to discuss scheduling, pricing, and how we can support your residents and community.
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