Get In Touch With Us

Facility or Organization Name *

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

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.