Foot Care Referral Complete this form to have one of our Care Managers contact you within 1 business day. "Required" indicates required fields Who are you looking for foot care for:RequiredMeMy SpouseMy ParentA Family MemberA FriendOtherYour Contact InfoNameRequired First Name Last Name EmailRequired PhoneRequiredHow should we contact you?Required Email Phone Care InformationClient's NameRequired First Name Last Name What community does the person receiving care reside in?RequiredBurlingtonHalton HillsHamiltonMiltonMississaugaOakvilleOtherWere you referred by the Burlington Family Health team?Required Yes No Where would you like to receive your foot care services?Required At home At our Burlington Nursing Clinic (4155 Fairview Street) At our Adult Day Program (for members only) Other DetailsThis field is hidden when viewing the formLanguages SpokenAnything else you'd like us to know? (Specific requirements, spoken languages, etc.)Permission to SubmitRequiredAcclaim Health is committed to individual privacy and has taken reasonable precautions to ensure the security of the information you are submitting through this online form. By clicking “I agree” you are acknowledging and accepting the potential risks inherent in submitting personal information and/or personal health information online. Please contact us by telephone at 905-827-8800 if you do not wish to submit this information online and we will be happy to assist you. I agree CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
